() \d RN ~e.if>\)eY1c'?'f\}i . MERCED COLLEGE 209.384.6000
Dean Counseling Bobby Anderson (209) 384-63 14 Nursing, Registered Phone Cooperative Work Experience (209) 384-6309 (209) 384-6364 Allied Health, Business and Public Safety Area Office AH C- 126
DEGREE and non-nursing breadth requirements. Graduates will AS. - Nursing, Registered earn the Associate of Science Degree upon completion of designated courses and competency requirements Web site www.mccd .edu/alliedhealth/ Program Application Applications are available from the division's web site and Program Description the college bookstore. It is the applicant's responsibility to All individuals who meet minimum enrollment requirements submit all required paperwork within the specified dates are eligible to apply to the nursing programs. Criteria and and times. Applications will be accepted during March, complete information on the selection process as well as the specifically during a 2-3 day window. Specific dates and philosophy and objectives of each program are described times will be noted on the web site. in the Nursing Application Handbook which is available in the Merced College Bookstore and online. The handbook Selection Process is extensive and may contain additional information to the The Merced College RN Program uses the California following brief program outline. Community College chancellor's model for selection of program applicants. The selection procedure will be a Completion of the Registered Nursing Program at bl ended combination of random selection and multi-criteria Merced College and all requirements of the AS. Degree screening process. Details are available online at www. qualify students to take the *National Council Licensure mccd.edu/alliedhealth/. Examination for Registered Nurses (NCLEX-RN). (It is the student's responsibility to meet all requirements to sit for the Using th e merit-based selection process above, those NCLEX-RN exam.) applicants scoring 80% or higher will be included in a merit *BRN-Boa rd of Registered Nursing; based selection pool. Randomized selection will be used to 1625 North Market Blvd; Suite N217; Sacramento, CA 95 834-1924; www.rn .ca .gov select an incoming class of students from th is merit-based selection pool. These students will be sequentially numbered Highlights from on e to the maximum allowed for the incoming class, The Allied Health Center houses a complete Registered including a predetermined number of alternate students. Nursing Skills Lab, large computer lab, conference rooms, study rooms and multiple large and small classrooms. The Depending on the number of qualified applicants and Registered Nursing Program has state-of-the-art equipment constraints of the Chancellor's Office Merit-based selection and software that assist students with learning current model, the merit-based selection pool will vary in size for procedures. each application period .
Mission Statement Multiple Applications The mission of the Merced College Registered Nursing There is no waiting list maintained for entrance into the RN Program is to prepare our students for careers as Program. Applicants applying to the program a second time professional Registered Nurses by providing a continually must reactivate their application and are responsible for improving educational program which is accredited by the updating their information to comply with local and/or state CA Board of Registered Nursing and by instilling in our requirements. It is possible to be accepted into the qualified students a commitment to continued professional growth merit-based selection pool more than one selection period. and lifelong learning. If an applicant has applied to the program more than once Nursing, Registered consecutively as a fully qualified applicant, the applicant's The Registered Nursing Program at Merced College name will be added to the application pool an additional prepares students to take the National Council Licensure time for each such application. Examination for Registered Nurses (NCLEX-RN), leading to licensure as a Registered Nurse (RN) and is designed Applicants who are selected and then declined OR are not to prepare competent nurses for service in the community. successful completing the first semester may apply ag ain The Registered Nursing Program requires two academic but will not be recognized as a "consecutive" applicant. years beyond the completion of th e prerequisite courses Applicants may only be accepted to the program a maximum
218 • Nursing, Registered • WWW.MCCD.EDU 2012-2013 CATALOG of two times. needed information during the phases of the nursing process). Requirements for Accepted Applicants Only C. A student will be able to utilize critical thinking ar( The following must be completed prior to starting the first problem solving during the phases of the nursing course in the RN Program: process. Health clearance (including necessary immunizations) D. A student will exhibit an (internalized) individual code Criminal background check (requires proof of valid social of ethics consistent with nursing professional standards security number) and apply this code solving ethical dilemmas of patient! CPR certification family care while acting as a patient advocate. Drug screening E. A student will exhibit leadersh ip and management skills while providing entry level competent, culturally Preassessment Testing Requirement sensitive quality care. Students selected into the RN Program must pass an assessment test (currently using TEAS). Applicants who do not meet the established score of 62 must attend DEGREE (2to7> a remediation program within one year in order to be A.S.- Nursing, Registered ( l2500.AS) considered for enrollment in the next RN class. Study materials are available in the Allied Health Office. Students Prerequisite courses: Units may submit a copy of a previous TEAS test score in lieu of BIOL-16** General Human Anatomy ...... 4 taking the test again . BIOL-18** Principles of Physiology...... 4 BIOL-2 0** Microbiology...... 4 CHEM-02A Introductory Chemistry ...... 4 Note to Transfer Students ENGL-01A College Composition and Reading ... 4 SECTION 1. Section 66055.8 of the Education Code is amended to read: ·~ It is highly recommended that once enrolled in these classes, students do not drop them. Program applicants need to understand that multiple attempts to improve grades earned in these classes can negatively affect 66055.8 Notwithstanding any other provision of law, a their eligibility. campus of the California State University or the California Community Colleges that operates a registered nursing Required courses (non-nursing) which also fulfil A.S. Bread" requirements: program shall not require a student who has been admitted ANTH-02 Cultural Anthropology ... 3 to that registered nursing program and who has already or earned a baccalaureate or higher degree from a regionally SOC-01 Introduction to Sociology .. 3 accredited institution of higher education to undertake any COMM-01 Fundamentals of Speech . ... 3 coursework other than the coursework that is unique and or exclusively required to earn a nursing degree from that COMM-05 Interpersonal Communication ...... 3 institution. CLDV-09*** Human Development (Also Psyc-09) ... 3
The System Office is interpreting this amendment to the HIST-17A Political and Social History of the United States. . . 3 Education Code as follows: or HIST-178 Political and Social History of the United States ...... 3 To obtain an associate degree in nursing, students who or POSC-01 Essentials of the American Political System ...... 3 have baccalaureate or higher degrees are only required to complete the course work required for completion of the HUM Any Humanities A.S. Breadth Area C (see cata log ) .. 3 registered nursing program, including prerequisites and PHED Any activity ...... 2 nursing course work. These students are not to be required ***Must be completed prior to or concurrently with REGN-25. to complete any other courses required by the college for an associate degree. Required courses (nursing): First Semester Program Student Learning Outcomes REGN-15 Nursing in Health and Illness I .... 9 REGN-16 Pharmacology I ...... 2 A. A student will be able to customize nursing interventions REGN-17 Nursing Skills Simulation I .... 1 utilizing a decision making process based upon their knowledge of pathophysiology, mathematical principles, Second Semester critical thinking, patient developmental levels and REGN-25 Nursing in Health and Illness II ...... 9 REGN-26 Pharmacology II ...... 2 cultural differences. REGN-27 Nursing Skills Simulation II B. A student will be able to collaborate with an interdisciplinary health care team to demonstrate and Third Semester utilize therapeutic communication techniques during REGN-35 Nursing in Health and Illness Ill ...... 9 REGN-36 Pharmacology Ill ...... ". 1 interactions with their clients (as well as to obtain REGN-37 Nursing Skills Simulation Ill .. . .. 1 • Nursing, Registered • 219 MERCED COLLEGE 209.384.6000 REGN-38 Professional Relationships and Responsibilities I ... . 1 ****Requ ired for LVN 's who have met admission selection criteria, have successfully completed REGN-01 and have been accepted into the Fourth Semester Registered Nursing Program's third semester. REGN-45 Nursing in Health and Illness IV ...... 9 REGN-46 Pharmacology IV...... 1 REGN-47 Nursing Skills Simulation IV ...... 1 Transfer REGN-48 Professional Relationships and Responsibilities II .... 1 Credits earned in the Merced College Registered Nursing Program may 65 be transferable to California State Universities. Since prerequisite science and social science courses vary at each institution , students are advised Competencies as required by Merced College for graduation: to consult the catalog of their intended transfer school and establish a Writing: Met by completion of ENGL-01A within program prerequisites. transfer plan with the Allied Health Counselor. Math: Met by MATH-Cor higher level math course. Reading: Met by completion of AS. Breadth courses with "C" grade or better. REGISTERED NURSING (REGN) REGN-01 TRANSITION LVN TO RN [Completion of the Registered Nursing Program at Merced College 2 units: 1 hour lecture, 3 hours lab. satisfies CILC areas A through G.] Limitation on enrollment: California VN license . Prerequisites: BIOL 16; BIOL-20; CHEM-02A; ENGL-01 A; BIOL-18. One-way corequisite: LVN toRN Pathway CLDV-09/PSYC-09 The pathway for California Licensed Vocational Nurses requires one The series of lectures and discussions will provide concepts and principles academic year beyond completion of the prerequisite courses, non-nursing necessary to facilitate transition of the LVN to the changing role of the breadth requirements, and competencies. LVN to RN students enter into registered nurse. Emphasis will be placed upon the registered nurse as a the third semester of the RN curriculum identified above after completion decision-making member of the health team, and of responsibilities to be of REGN-01 and all other prerequisites. Applicants submit an application assumed by such a practitioner. (1 0/06) found on the Allied Health web site. Graduates will earn the Associate in Science Degree on completion of designated courses and competency REGN -02 CLINICAL SKILLS TRANSITION- LVN TORN requirements. Communication , natural and social science, and nursing 1 unit: 3 hours lab. courses must be completed with a grade of "C " or better to be eligible for Limitation on enrollment: California VN license, enrolled in REGN licensure requirements of the State Board of Nursing . Program 3rd semester. Prerequisites: REGN-01 . One-way corequisite: REGN-35. Enrollment eligibility to the LVN to RN pathway requires the completion This course consists of practice in the clinical setting with ski ll s and of previously identified prerequisite courses. Applicants must meet the principles necessary to facilitate transition of the LVN to the changing role same selection requirements as generic RN students entering the program of the registered nurse. Clinical hours must be initiated in the first week of in the first semester. In addition , CLDV-09/PSYC-09 are prerequisites the semester enrolled. Emphasis is placed on nursing skills related to first for the LVN to RN applicant who has already met the selection criteria. year RN nursing concepts in clinical practice. (1/08) Randomized selection is used to select a cohort from the pool of qualified applicants according to available ·seats. REGN-15 NURSING IN HEALTH AND ILLNESS I [CILC Area B,C,D,E,F,G] LVN to RN applicants are notified of eligibility approximately two months 9 units: 4 hours lecture, 15 hours lab. prior to the next semester. The LVN-RN application period remains open . Limitation on enrollment: 1) Enrollment in the REGN program, 2) CPR To progress into the RN program, students must successfully complete card Module AC , 3) physical within past 6 months, 4) negative TB the REGN-01 LVN to RN transition class which is offered when a sufficient screen in g test within past 6 months or negative chest x-ray within number of qualified applicants exist. past year, 5) proof of current immunizations, 6) criminal background clearance, 7) proof of current malpractice insurance, and 8) drug Space in the RN program is determined based on the number of RN screening. Prerequisites: BIOL-16, BIOL-18, BIOL-20; CHEM-02A; students progressing from the second semester to the third semester. ENGL-01A. Two-way corequisites: REGN-16, REGN-17. Advisory: REGN-50. Applicants selected from the pool must complete the assessment test This course presents basic concepts that provide the foundation upon which (currently using TEAS). A score less than 67 requires the applicant to homeostasis is maintained in adults and/or children. Common threads complete the same remediation requirements as all other generic RN integrated throughout the program are initiated: nursing process, nutrition , students before admission into the program. Only those students pharmacology, developmental levels, cultural diversity, communication, formally accepted into the program may register for courses identified as and professional role. (1/09) Registered Nursing Curriculum. Students may, however, enroll in other courses designated as non-nursing program requirements while awaiting REGN-16 PHARMACOLOGY I selection into the program. 2 units: 2 hours lecture. Limitation on enrollment: Enrollment in the REGN Program. Two-way Third Semester corequisite: REGN-15. Advisory: VOCN-46A. REGN-02**** Clinical Skills Transition - LVN to RN ...... 1 This course presents introductory concepts of pharmacology and drug REGN-35 Nursing in Health and Illness Ill...... 9 adm inistration with focus on laxatives/antidiarrheageal, hypoglycemics, REGN-36 Pharmacology 111 ...... 1 and analgesics/anti-inflammatory agents and basic math. (1/09) REGN-37 Nursing Skills Simulation 111...... 1 REGN -38 Professional Relationships and Responsibilities 1.... . 1 REGN-17 NURSING SKILLS SIMULATION I [CILC Area A] Fourth Semester 1 unit: 3 hours lab. REGN-45 Nursing in Health and Illness IV ...... 9 Limitation on enrollment: Enrollment in the REGN program. Two-way REGN-46 Pharmacology IV ...... 1 corequisite: REGN-15. REGN-47 Nursing Skills Simulation IV ...... 1 This course includes instruction/demonstration and return demonstration REGN-48 Professional Relationships and Responsibilities II .... 1 of nursing skills related to the first year nursing concepts. This course 25 emphasizes skills and knowledge applications. (11 /08)
220 • Nursing, Registered • WWW.MCCD.EDU 2012-2013 CATALOG REGN-25 NURSING IN HEALTH AND ILLNESS II REGN-45 NURSING IN HEALTH AND ILLNESS IV 9 units: 4 hours lecture, 15 hours lab. 9 units: 4 hours lecture, 15 hours lab. Limitation on enrollment: Enrollment in the REGN program 2nd Limitation on enrollment: Enrollment in the REGN program 4( semester. Prerequisites: REGN-15, REGN-16. One-way corequisite: semester. Prerequisites: REGN-35. One-way corequisite: REGI'<· CLDV-09/PSYC-09, Two-way corequisite: REGN-26, REGN-27. 48. Two-way corequisite: REGN-46, REGN-47. This course enlarges upon the concepts presented in REGN-15, This course presents advanced concepts and skills in caring for the client introducing principles of care to maintain and restore normal homeostatic with critical or multiple health problems. It emphasizes rehabilitation and mechanisms in patients of all ages; study of the family unit throughout the adaptation to a compromised and/or declining health status. Concurrent life cycle is included, with emphasis on preventive care. (1/09) practice in the college lab and clinical experience in community health facility is required. (1/09) REGN-26 PHARMACOLOGY II 2 units: 2 hours lecture. REGN-46 PHARMACOLOGY IV Limitation on enrollment: Enrollment in the REGN program 2nd 1 unit: 1 hour lecture. semester. Prerequisites: REGN-16. Two-way corequisite: REGN-25 Limitation on enrollment: Enrollment in the REGN program 4th Advisory: VOCN-46A semester. Prerequisites: REGN-36. Two-way corequisite: REGN- This course presents introductory concepts of pharmacology and mediation 45. for infectious diseases, hypertension, anemias, family/OB. (1/09) This course presents ongoing concepts of pharmacology for psychiatric (aduiUteenagers), shock, cardiac arrhythmias, neurological and REGN-27 NURSING SKILLS SIMULATION II neuromuscular, and endocrine conditions. (01/09) 1 unit: 3 hours lab. Limitation on enrollment: Enrollment in the REGN program 2nd REGN-47 NURSING SKILLS SIMULATION IV semester. Prerequisites: REGN-17. Two-way corequisite: REGN-25. 1 unit: 3 hours lab . This course includes instruction/demonstration and return demonstration Limitation on enrollment: Enrollment in the REGN program 4th of nursing skills related to the first year nursing concepts. This course semester. Prerequisite: REGN-37. Two-way corequisite: REGN-45. emphasizes skills and knowledge applications. (11 /08) This course presents instruction and demonstration of higher level nursing concepts related to second-year nursing courses. The second-year REGN-35 NURSING IN HEALTH AND ILLNESS Ill student will assume a facilitator role with other nursing students in nursing 9 units: 4 hours lecture, 15 hours lab. care planning. (1 0/06) Limitation on enrollment: 1) Enrollment in the REGN program 3rd semester, 2) CPR card Module AC, 3) physical within past 6 months, REGN-48 PROFESSIONAL RELATIONSHIPS AND 4) negative TB screening test within past 6 months or negative chest RESPONSIBILITIES II x-ray within past year, 5) proof of current immunizations, 6) criminal 1 unit: 1 hour lecture. background clearance, 7) drug screening , and 8) proof of current Limitation on enrollment: Enrollment in the REGN program 4th malpractice insurance. Prerequisites: CLDV-09/PSYC-09; REGN-25 semester. Prerequisite: REGN-38. One-way corequisite: REGN-45. or REGN-01. One-way corequisite: REGN-38. Two-way corequisite: This course is an introduction to leadership and management principl{ REGN-36, REGN-37. applied to the health care field . Discussions will include leadership ana This course enlarges upon the concepts presented in REGN-15 and REGN- management theories, organizational structure, problem-solving, decision 25 by introducing principles of care to maintain and/or restore homeostatic making, conflict management, effective communication, change process, mechanisms in acute health problems. Prototype disease processes planning process, motivational theories, and performance appraisal. associated with each concept are studied in relation to preventive and (10/06) restorative nursing care. Concurrent practice in the college laboratory and clinical experience in community facilities are required. (1/09) REGN-49A-ZZ SPECIAL TOPICS IN NURSING .5-3 units: .5-3 hours lecture, 0-6 hours lab. REGN-36 PHARMACOLOGY Ill Limitation on enrollment: Enrollment in an accredited nursing program, 1 unit: 1 hour lecture. or a graduate from an accredited nursing program, or possession of Limitation on enrollment: Enrollment in the REGN program 3RD a valid nursing license. semester. Prerequisite: REGN-26 . Two-way corequisite: REGN-35. This course is designed to address special topics in nursing to meet the This course presents ongoing concepts of pharmacology compatible with current needs of students. It will provide students access to instruction respiratory, cardiac/vascular, cancer, DMARDs and immunosuppressant that will assist them in acquiring the most up-to-date information possible therapies for adults and children. (1 /09) in order to cope with the rapidly changing health care environment. (2/08)
REGN -37 NURSING SKILLS SIMULATION Ill REGN-50 NURSING CAREER SEMINAR 1 unit: 3 hours lab. .25 unit: 4.5 total hours lecture. Limitation on enrollment: Enrollment in the REGN program 3rd Prerequisite/Advisory: None. semester. Prerequisite: REGN-27. Two-way corequisite: REGN-35. This course introduces students to the various roles and responsibilities This course presents demonstration of higher-level nursing concepts of nursing practitioners, including knowledge of educational levels as well related to second-year nursing courses. The third-semester student will as behaviors and skills. Merced College nursing programs are described, assume the facilitator role with other nursing students in skill check-offs. including admission requirements and procedures. Students are graded (11/08) on credit/no credit basis. May be repeated once. (1 0/06)
REGN-38 PROFESSIONAL RELATIONSHIPS AND RESPONSIBILITIES I 1 unit: 1 hour lecture. Limitation on enrollment: Enrollment in the REGN program 3rd semester. One-way corequisite: REGN-35 . The course introduces the student to the professional role of the registered nurse: its status, its responsibilities, and inherent problems as influenced by historical and social change. The focus is on the individual nurse and on th e profession as a whole. (1/09)
• Nursing, Registered • 221 Nev.J RtJ Se'Dv~V1c?n0 , MERCED COLLEGE 209.384.6000
DEAN COUNSELING BOBBY ANDERSON (209) 384-6314 Nursing, Registered PHONE COOPERATIVE WORK EXPERIENCE (209) 384-6309 (209) 384-6364 ' ALLIED HEALTH, BUSINESS AND .PUBLIC SAFETY AREA OFFICE AHC-126
DEGREE and non-nursing breadth requirements. Graduates will A.S ., Nursing, Registered earn the Associate of Science Degree upon completion of designated courses and competency requirements. Website 1/'NVW.mccd.edu/alliedhealth/ Program Application Applications are available from the division's web site and Program Description the college bookstore. It is the applicant's responsibility to All individuals who meet minimum enrollment requirements submit all required paperwork within the specified dates are eligible to apply to the nursing programs. Criteria and and times. Applications will be accepted during March, complete information on the selection process as well as the specifically during a 2-3 day window. Specific dates and philosophy and objectives of each program are described times will be noted on the web site. in the Nursing Application Handbook which is available in the Merced College Bookstore and online. The handbook Selection Process is extensive and may contain additional information to the The Merced College RN Program uses the California following brief program outline. Community Col lege chancellor's model for selection of program applicants. The selection procedure will be a Completion of the Registered Nursing Program at blended combination of random selection and multi-criteria Merced College and all requirements of the A.S. Degree screening process. Details are available online at www. qualify students to take the *National Council Licensure mccd.edu/alliedhealth/. Examination for Registered Nurses (NCLEX-RN). (It is the student's responsibility to meet all requirements to sit for the Using the merit-based selection process above, those NCLEX-RN exam.) applicants scoring 80% or higher will be included in a merit *BRN-Board of Registered Nursing; based selection pool. Randomized selection will be used to 1625 North Market Blvd ; Suite N217; Sacramento, CA 95834-1924; www.rn .ca .gov select an incoming class of students from this merit-based selection pool. These students will be sequentially numbered Highlights from one to the maximum allowed for the incoming class, The Allied Health Center houses a complete Registered including a predetermined number of alternate students. Nursing Skills Lab, large computer lab, conference rooms, study rooms and multiple large and small classrooms. The Depending on the number of qualified applicants and Registered Nursing Program has state-of-the-art equipment constraints of the Chancellor's Office Merit-based selection and software that assist students with learning current model, the merit-based selection pool will vary in size for procedures. each application period.
Mission Statement Multiple Applications The mission of the Merced College Registered Nursing There is no waiting list maintained for entrance into the RN Program is to prepare our students for careers as Program. Applicants applying to the program a second time professional Registered Nurses by providing a continually must reactivate their application and are responsible for improving educational program which is accredited by the updating their information to comply with local and/or state CA Board of Registered Nursing and by instilling in our requirements. It is possible to be accepted into the qualified students a commitment to continued professional growth merit-based selection pool more than one selection period. and lifelong learning. If an applicant has applied to the program more than once Nursing, Registered consecutively as a fully qualified applicant, the applicant's The Registered Nursing Program at Merced College name will be added to the application pool an additional prepares students to take the National Council Licensure time for each such application. Examination for Registered Nurses (NCLEX-RN), leading to licensure as a Registered Nurse (RN) and is designed Applicants who are selected and then declined OR are not to prepare competent nurses for service in the community. successful completing the first semester may apply again The Registered Nursing Program requires two academic but will not be recognized as a "consecutive" applicant. years beyond the completion of the prerequisite courses Applicants may only be accepted to the program a maximum
212 • Nursing, Registered • WWW.MCCD.EDU 2013-2014 CATALOG of two times. Program Student Learning Outcomes A. Provide quality, safe, patient-center nursing care through evidence Requirements for Accepted Applicants Only based practice. The following must be completed prior to starting the first B. Participate in collaborative relationships with members of the course in the RN Program: interdisciplinary team to provide and improve patient care. Health clearance (including necessary immunizations) C. Engage in critical thinking skills and strategies and clinical rea soning necessary to provide quality patient care. Criminal background check (requires proof of valid social D. Provide leadership in a variety of healthcare settings for diverse security number) patient populations. CPR certification E. Use information technology to communicate, manage knowledge, Drug screening mitigate error, and support decision-making. F. Function as a competent nurse assimilating all professional, ethical, and legal principles . Preassessment Testing Requirement Students selected into the RN Program must pass an Prerequisite courses: Units assessment test (currently using TEAS). Applicants who BIOL-16** General Human Anatomy (meets Area B2)...... 4 BIOL-18** Principles of Physiology ...... 4 do not meet the established score of 62 must attend BIOL-20** Microbiology ...... 4 a remediation program within one year in order to be ENGL-01A College Composition and Reading (meetsAreaA1) .4 considered for enrollment in the next RN class. Study MATH-C Intermediate Algebra ...... 4 materials are available in the Allied Health Office. Students ** It is highly recommended that once enrolled in these classes, students may submit a copy of a previous TEAS test score in lieu of do not drop them. Program applicants need to understand that multiple taking the test again. attempts to improve grades earned in these classes can negatively affect their eligibility. Note to Transfer Students Required courses (non-nursing) which also fulfil A.S. Breadth SECTION 1. Section 66055.8 of the Education Code is requirements: amended to read: COMM-01 Fundamentals of Speech (meets area A2) ...... 3 or 66055.8 Notwithstanding any other prov1s1on of law, a COMM-01H Honors Fundamentals of Speech (3) or campus of the California State University or the California COMM-04 Small Group Discussion & Problem Solving (3) Community Colleges that operates a registered nursing or program shall not require a student who has been admitted COMM-05 Interpersonal Communication (3) to that registered nursing program and who has already Area B1 Physical Science (CHEM-02A recommended) ...... 3 Area C Humanities ...... 3 earned a baccalaureate or higher degree from a regionally Area D1 Behavioral Science (ANTH-02 recommended) ...... 3 accredited institution of higher education to undertake any Area D2 Social Science ...... 3 coursework other than the coursework that is unique and Area E1 Integrated Organism ...... 3 exclusively required to earn a nursing degree from that Area E2 Activity ...... 2 institution. Required courses (nursing): First Semester The System Office is interpreting this amendment to the REGN-15 Foundations of Nursing ...... 9 Education Code as follows: REGN-18 Pharmacology In Nursing Practice ...... 3 Second Semester To obtain an associate degree in nursing, students who REGN-24 Acute Medical/Surgical and Nursing of the have baccalaureate or higher degrees are only required Childbearing Family ...... 10 to complete the course work required for completion of the Third Semester registered nursing program, including prerequisites and REGN-34 Advanced Medical/Surgical Nursing and Pediatric nursing course work. These students are not to be required Nursing ...... 10 to complete any other courses required by the college for an associate degree. Fourth Semester REGN-44 Acute Medical/Surgical Nursing and Mental Health Nursing ...... j! DEGREE (2/13) 81
A.S. - Nursing, Registered ( 12500.AS) Competencies as required by Merced College for graduation: Writing: Met by completion of ENGL-01A within program prerequisites. The Registered Nursing Program at Merced College prepares students to Math: Met by MATH-C or higher level math course. take the National Council Licensure examination for Registered Nurses Reading: Met by completion of A.S. Breadth courses with "C" grade or (NCLEX-RN}, leading to licensure as a Registered Nurse (RN) and better. is designed to prepare competent nurses for service in the community. The Registered Nursing Program requires two academic years beyond [Completion of the Registered Nursing Program at Merced Co llege the completion of the prerequisite courses and non-nursing breadth satisfies CILC areas A through G.] requirements. Graduates will earn the Associate in Science Degree upon completion of designated courses and competency requirements.
• Nursing, Registered • 213 MERCED COLLEGE 209.384.6000 LVN TO RN PATHWAY registered nurse. Emphasis will be placed upon the registered nurse as a The pathway for California Licensed Vocational Nurses requires one decision-making member of the health team. and of responsibilities to be academic year beyond completion of the prerequisite courses, non-nursing assumed by such a practitioner. (1 0/06) breadth requirements. and competencies. LVN to RN students enter into the third semester of the RN curriculum identified above after completion REGN-02 CLINICAL SKILLS TRANSITION - LVN TO RN of REGN-01 and all other prerequisites. Applicants submit an application 1 unit: 3 hours lab. found on the Allied Health web site. Graduates will earn the Associate in Limitation on enrollment: California VN license, enrolled in REGN Science Degree on completion of designated courses and competency Program 3rd semester. Prerequisites: REGN-01 . One-way requirements. Communication, natural and social science. and nursing corequisite: REGN -35 . courses must be completed with a grade of "C" or better to be eligible for This course consists of practice in the clinical setting with skills and licensure requirements of the State Board of Nursing . principles necessary to facilitate transition of the LVN to the changing role of the registered nurse. Clinical hours must be initiated in the first week of Enrollment eligibility to the LVN to RN pathway requires the completion the semester enrolled. Emphasis is placed on nursing skills related to first of previously identified prerequisite courses. Applicants must meet the year RN nursing concepts in clinical practice. (1108) same selection requirements as generic RN students entering the program in the first semester. In addition, CLDV-09/PSYC-09 are prerequisites REGN-15 FOUNDATIONS OF NURSING for the LVN to RN applicant who has already met the selection criteria . [CILC Area B,C,D,E,F,G] Ra ndomized selection is used to select a cohort from the pool of qualified 9 units: 4 hours lecture, 15 hours lab TBA. applicants according to available seats. Limitation on enrollment: 1) Enrollment in the REGN program, 2) CPR card Module AC, 3) physical within past 6 months, 4) negative TB LVN to RN applicants are notified of eligibility approximately two months screening test within past 6 months or negative chest x-ray within prior to the next semester. The LVN-RN application period remains open. past year, 5) proof of current immunizations, 6) criminal background To progress into the RN program. students must successfully complete clearance, 7) drug screening. Prerequisites: BIOL-16, BIOL-18, the REGN-01 LVN toRN transition class which is offered when a sufficient BIOL-20; ENGL-01A; MATH-C. Two-way corequisites: REGN-18. number of qualified applicants exist. Registered Nursing 15 (Foundations of Nursing) focuses on foundational concepts necessary for safe, patient-centered nursing care to a diverse Space in the RN program is determined based on the number of RN patient population while integrating legal and ethical responsibilities of the students progressing from the second semester to the third semester. nurse. Introduces critical thinking applied to nursing, the nursing process, diversity, and communication techniques used when interacting with Applicants selected from the pool must complete the assessment test patients and members of the interdisciplinary team, and app lies evidence (currently using TEAS). A score less than 67 requires the applicant to based nursing practice. Includes acquisition of basic nursing skills. complete the same remediation requirements as all other generic RN Application of knowledge and skills occurs in the nursing skills laboratory students before admission into the program. Only those students and a variety of acute and long-term care clinical settings. (2/13) formally accepted into the program may register for courses identified as Registered Nursing Curriculum. Students may, however, enroll in other REGN-17 NURSING SKILLS SIMULATION I courses designated as non-nursing program requirements while awaiting [CILC Area A] selection into the program. 1 unit: 3 hours lab . Limitation on enrollment: Enrollment in the REGN program. Two-way Second Semester corequisite: REGN-15. REGN-01 Transition LVN to RN ...... 2 This course includes instruction/demonstration and return demonstration of nursing skills related to the first year nursing concepts. This course Third Semester emphasizes skills and knowledge applications. (11/08) REGN-02**** Clinical Skills Transition- LVN to RN ...... 1 REGN-34 Advanced Medical/Surgical Nursing and Pediatric REGN-18 PHARMACOLOGY IN NURSING PRACTICE Nursing ...... 10 3 units: 3 hours lecture. Limitation on enrollment: Enrollment in the REGN Program. Two-way Fourth Semester corequisite: REGN-15. Advisory: VOCN-46A. REGN-44 Acute Medical/Surgical Nursing and Mental Health Registered Nursing 18, Pharmacology in Nursing Practice, presents an overview of the basic principles of pharmacology including major drug Nursing ...... ~ 22 classifications and prototypes. Principles of medication administration include all aspects of best practice for safe, quality, patient-centered ****Required for LVN's who have met admission selection criteria have care including developmentally and culturally appropriate interventions. successfully completed REGN-01 and have been accepted into the Includes dosage calculations. (2/13) Registered Nursing Program's third semester. REGN-24 ACUTE MEDICAL/SURGICAL AND NURSING OF THE Transfer CHILDBEARING FAMILY Cred its earned in the Merced College Registered Nursing Program may 10 units: 5 hours lecture, 15 hours lab TBA. be transferable to California State Universities. Since prerequisite science Limitation on enrollment: Enrollment in the REGN program 2nd and social science courses vary at each institution. students are advised semester. Prerequisite: REGN-15, REGN-18. to consult the catalog of their intended transfer school and establish a Registered Nursing 24 provides for the acquisition and application of transfer plan with the Allied Health Counselor. nursing theory, communication , collaboration. and critical thinking skills necessary for safe, patient-centered nursing care to a developmentally and culturally diverse patient populations experiencing various common REGISTERED NURSING (REGN} medical/surgical interventions and to the childbearing family. Incorporates REGN-01 TRANSITION LVN TO RN best practices. professional standards, and legal and ethical responsibilities 2 units: 1 hour lecture, 3 hours lab. of the professional nurse as applied in various healthcare settings. Includes Limitation on enrollment: California VN license . Prerequisites: BIOL acquisition of nursing skills required in acute care and childbearing family 16; BIOL-20; CHEM-02A; ENGL-01A; BIOL-18. One-way corequisite: settings. Application of knowledge and skills occurs in the nursing skills CLDV-09/PSYC-09 laboratory and clinical settings. (2/13) The series of lectures and discussions will provide concepts and principles necessary to facilitate transition of the LVN to the changing role of the REGN-25 NURSING IN HEALTH AND ILLNESS II
214 • Nursing, Registered • WWW.MCCD.EDU 2013-2014 CATALOG 9 units: 4 hours lecture, 15 hours lab. related to second-year nursing courses. The third-semester student will Limitation on enrollment: Enrollment in the REGN program 2nd assume the facilitator role with other nursing students in skill check-offs. ( semester. Prerequisites: REGN-15, REGN-18. One-way corequisite: (11/08) CLDV-09/PSYC-09, Two-way corequisite: REGN-26, REGN-27. This course enlarges upon the concepts presented in REGN-15 , REGN-38 PROFESSIONAL RELATIONSHIPS AND introducing principles of care to maintain and restore normal homeostatic RESPONSIBILITIES I mechanisms in patients of all ages; study of the family unit throughout the 1 unit: 1 hour lecture. life cycle is included, with emphasis on preventive care. (1/09) Limitation on enrollment: Enrollment in the REGN program 3rd semester. One-way corequisite: REGN-35. REGN-26 PHARMACOLOGY II The course introduces the student to the professional role of the registered 2 units: 2 hours lecture. nurse : its status, its responsibilities, and inherent problems as influenced Limitation on enrollment: Enrollment in the REGN program 2nd by historical and social change. The focus is on the individual nurse and on semester. Prerequisites: REGN-18. Two-way corequisite: REGN-25 the profession as a whole. (1/09) Advisory: VOCN-46A This course presents introductory concepts of pharmacology and mediation REGN-44 ACUTE MEDICAL/SURGICAL NURSING AND MENTAL for infectious diseases, hypertension, anemias, family/08. (1/09) HEALTH NURSING 9 units: 4 hours lecture, 15 hours lab. REGN-27 NURSING SKILLS SIMULATION II Limitation on enrollment: Enrollment in the REGN program 4th 1 unit: 3 hours lab. semester. Prerequisite: REGN-34. Limitation on enrollment: Enrollment in the REGN program 2nd Registered Nursing 44 builds on REGN-34, focusing on complex medical/ semester. Prerequisites: REGN-17. Two-way corequisite: REGN-25. surgical conditions of the high acuity patient and the patient at various This course includes instruction/demonstration and return demonstration levels of mental health promotion and mental illness management. Builds of nursing skills related to the first year nursing concepts. This course on nursing theory, communication, collaboration, and critical thinking skills emphasizes skills and knowledge applications. (11/08) necessary for safe, patient-centered nursing care to developmentally and culturally diverse patient populations. Incorporates best practices, REGN-34 ADVANCED MEDICAL/SURGICAL NURSING AND professional standards, and legal and ethical responsibilities of the PEDIATRIC NURSING professional nurse as applied in the acute care and mental health 10 units: 5 hours lecture, 15 hours lab TBA. settings incorporating all aspects of the professional nurse. Application of Limitation on enrollment: Enrollment in the REGN program 3rd knowledge and skills occurs in the acute care and community settings to semester; CPR card Module AC; physical within past 6 months; facilitate an effective transition from student to registered nurse. (2/13) negative TB screening test within past 6 months or negative chest x-ray within past year; proof of current immunizations; criminal REGN-45 NURSING IN HEALTH AND ILLNESS IV background clearance; drug screening. Prerequisite: REGN-01 or 9 units: 4 hours lecture, 15 hours lab. REGN-24. Limitation on enrollment: Enrollment in the REGN program 4th This course enlarges upon the concepts presented in REGN-15 and REGN- semester. Prerequisites: REGN-35 . One-way corequisite: REGN- 24 by introducing principles of care to maintain and/or restore homeostatic 48. Two-way corequisite: REGN-46 , REGN-47. mechanisms in acute health problems. Prototype disease processes This course presents advanced concepts and skills in caring for the client associated with each concept are studied in relation to preventive and with critical or multiple health problems. It emphasizes rehabilitation and restorative nursing care. Concurrent practice in the college laboratory and adaptation to a compromised and/or declining health status. Concurrent clinical experience in community facilities are required. (2/13) practice in the college lab and clinical experience in community health facility is required . (1/09) REGN-35 NURSING IN HEALTH AND ILLNESS Ill 9 units: 4 hours lecture, 15 hours lab. REGN-46 PHARMACOLOGY IV Limitation on enrollment: 1) Enrollment in the REGN program 3rd 1 unit: 1 hour lecture. semester, 2) CPR card Module AC, 3) physical within past 6 months, Limitation on enrollment: Enrollment in the REGN program 4th 4) negative TB screening test within past 6 months or negative chest semester. Prerequisites: REGN-36. Two-way corequisite: REGN- x-ray within past year, 5) proof of current immunizations, 6) criminal 45. background clearance, 7) drug screening, and 8) proof of current This course presents ongoing concepts of pharmacology for psychiatric malpractice insurance. Prerequisites: CLDV-09/PSYC-09; REGN-25 (adull/teenagers), shock, cardiac arrhythmias, neurological and or REGN-01. One-way corequisite: REGN-38. Two-way corequisite: neuromuscular, and endocrine conditions. (1/09) REGN-36, REGN-37. This course enlarges upon the concepts presented in REGN-15 and REGN- REGN-47 NURSING SKILLS SIMULATION IV 25 by introducing principles of care to maintain and/or restore homeostatic 1 unit: 3 hours lab. mechanisms in acute health problems. Prototype disease processes Limitation on enrollment: Enrollment in the REGN program 4th associated with each concept are studied in relation to preventive and semester. Prerequisite: REGN-37. Two-way corequisite: REGN-45. restorative nursing care. Concurrent practice in the college laboratory and This course presents instruction and demonstration of higher level nursing clinical experience in community facilities are required. (1/09) concepts related to second-year nursing courses. The second-year student will assume a facilitator role with other nursing students in nursing REGN-36 PHARMACOLOGY Ill care planning. (1 0/06) 1 unit: 1 hour lecture. Limitation on enrollment: Enrollment in the REGN program 3RD REGN-48 PROFESSIONAL RELATIONSHIPS AND semester. Prerequisite: REGN-26. Two-way corequisite: REGN-35. RESPONSIBILITIES II This course presents ongoing concepts of pharmacology compatible with 1 unit: 1 hour lecture. respiratory, cardiac/vascular, cancer, DMARDs and immunosuppressant Limitation on enrollment: Enrollment in the REGN program 4th therapies for adults and children. (1/09) semester. Prerequisite: REGN-38. One-way corequisite: REGN-45. This course is an introduction to leadership and management principles REGN-37 NURSING SKILLS SIMULATION Ill applied to the health care field . Discussions will include leadership and 1 unit: 3 hours lab. management theories, organizational structure, problem-solving, decision Limitation on enrollment: Enrollment in the REGN program 3rd making, conflict management, effective communication, change process, semester. Prerequisite: REGN-27. Two-way corequisite: REGN-35. planning process, motivational theories, and performance appraisal. This course presents demonstration of higher-level nursing concepts (10/06)
• Nursing, Registered • 215 Merced College REGN15
Foundations of Nursing
Fall 2013
Wanda Schindler, RN, MSNEd Dan Smith, RN, MSN, FNP
T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Faii2013\REGN 15\REGN 15 Foundations of Nursing Syllabus.docx Merced College REGN15 Foundations of Nursing Table of Contents
Instructor Information ...... 1 Using This Syllabus in Your Learning ...... 3 Introduction to the RN Program ...... 4 Calendar ...... 5 REGN-15 Course Description ...... 13 Clinical Principles/Confidentiality ...... 14 Course SLO's & Competencies ...... 15 Course Syllabus ...... 78 Student Clinical Objectives ...... 89 Critical Elements Level I ...... 90 Important Student's Note ...... 94 Written & Practice Skills Exam ...... 96 Clinical Site Maps ...... 97 Clinical Guidelines ...... 100 Quick Chart Review ...... 101 Health Insurance Portability & Accountability Act of 1996 (HIPAA) ...... 102 Confidentiality ...... 104 Geriatric Experiences- Residents Rights ...... 105 An Old Lady's Poem ...... 106 Vital Signs ...... 107 Assessing Body Temperature ...... 109 Assessing for an Apical-Radial Pulse Deficit ...... 111 Assessing Peripheral Pulses ...... 112 Assessing Respirations ...... 113 Assessing the Apical Pulse ...... 114 Assessing the Blood Pressure ...... 115 Monitoring Pulse Oximetry (Arterial Oxygen Saturation) ...... 117 Medical Abbreviations & Symbols List ...... 119 Guidelines for Documentation ...... 125 Hand Washing ...... 126 Hand Hygiene ...... 128 Intravenous lnfusions ...... 129 Restraints ...... 131 Using Restraints ...... 132 Universal Precautions/Protective Equipment ...... 134 Donning Personal Protective Equipment (PPE) ...... 135 Removing Personal Protective Equipment (PPE) ...... 137 Transmission Based Isolation Precautions ...... 139 Making an Occupied Bed ...... 140 Making an Unoccupied Bed ...... 143 Providing Oral Care for an Unconscious Patient...... 145 Providing Denture Care ...... 147 Oral & Denture Care ...... 149 Bathing & Peri care ...... 150 Providing Perineal Care ...... 151 Bathing: Providing a Complete Bed Bath ...... 153 Range of Motion ...... 155 Positioning, Transfer & Ambulation ...... 157 General Guidelines ...... 158 Degrees of Assistance Defined ...... 161 Transferring a Patient from Bed to Chair ...... 162 Use of a Patient Mechanical Lift ...... 164 Urine Sample- Foley (Sterile), Clean Catch ...... 167 Obtaining a Clean-Catch Urine Specimen ...... 168 Obtaining a Sterile Specimen from a Foley Catheter ...... 170 Hot & Cold Applications ...... 171 Blood Glucose Testing & Monitoring ...... 173 Checking Fingerstick (Capillary) Blood Glucose Levels ...... 174 Oxygenation, Airways, Nasal Cannulas, Masks ...... 176 Enemas ...... 178 Administering an Enema ...... 179 Physical Assessment (LPAT) ...... 184 Intake and Output: Charting ...... 187 Normal Fluid Intake & Output...... 188 I & 0 Sheet ...... 189 Catheter Care & Discontinue ...... 190 Removing an Indwelling Catheter ...... 191 Sterile Field, Open Gloving, Dressings & Bandages ...... 193 Applying Sterile Gloves (Open Method) ...... 195 Preparing and Maintaining a Sterile Field ...... 196 Applying and Removing Dry Dressings ...... 198 Applying and Removing Wet-to-Damp Dressings ...... 200 Applying Binders ...... 202 Elastic Bandage ...... 204 Urinary Catheters ...... 205 Inserting an Indwelling Urinary Catheter (Female) ...... 206 Inserting an Indwelling Urinary Catheter (Male) ...... 21 0 Applying a Condom Catheter (Male) ...... 214 Changing an Ostomy Appliance ...... 215 Clinical Guidelines for Administering Medications ...... 217 Preparing Medications ...... 218 Oral & Topical Medication ...... 223 Steps to Follow for all Medications, Regardless of Type or Route ...... 225 Administering Oral Medications ...... 227 Administering Topical Medications ...... 229 Administration of Injections ...... 231 Administration of a Subcutaneous Injection of Heparin ...... 233 Administration of a Subcutaneous Injection of Mixed Insulin ...... 238 Administration of Intradermal Injections ...... 241 Administration of Intramuscular Injections ...... 244 Locating Intramuscular Injection Sites ...... 248 Ophthalmic, Otic, Vaginal & Rectal Drug Administration ...... 252 Administering Vaginal Medications ...... 254 Administering Rectal Suppository ...... 256 Inhaled & Nasal Drug Administration ...... 258 Administering Medications Metered-Dose Inhaler Medication ...... 260 Administering Nasal Medications ...... 262 Administering Ophthalmic Medications ...... 264 Administering Otic Medications ...... 266 Gavage/Lavage- NG/GT Medications ...... 268 Administering Feedings Through Gastric and Enteric Tubes ...... 270 Administering Feedings Through an Enteral Tubes ...... 274
If you have a verified physical, medical, psychological, or learning disability or perhaps you feel you may have one of these disabilities which impact your ability to carry out assigned course work, please contact the Disabled Student Services (DSS) office. DSS staff will review your needs and determine what accommodations are necessary and appropriate. All information and documentation is confidential. DSS is located in the Lesher Student Services Bldg. Room 234, phone 384-6155. In Los Banos, DSS is located in Building A, phone 381-6423. Merced College Instructor Information
Instructor: Wanda Schindler, RN, MSNEd
Phone: 209-384-6128
Pager: 388-2788 (for clinical use only)
Instructor: Dan Smith, RN, MSN, FNP
Phone: 209-384-6127
1 Instructor reserves the right to modify the syllabus in response to changing student or pedagogical needs.
2 Merced College 151 Semester Syllabus (REGN 15)
Using This Syllabus in Your Learning This syllabus is divided into specific parts of learning objectives. You should utilize what has been included in this syllabus to facilitate your learning. As a nursing student you are expected to be actively involved in your learning. This syllabus is an adjunct to the lectures, theory in textbooks, and clinical experience. Some suggestions to assist you are: I. Read the assigned parts of the textbook as listed in the syllabus. II. Read assigned portions of the syllabus. Ill. Read the objectives and write an answer/explanation for each one. Be sure that you understand them. Try them yourself first, after reading the assigned readings, and then talk about them with your study group. IV. Download lecture note pages for taking notes during reading and lectures. V. Read the principles as provided; think of them as guidelines to the required theory. VI. Complete as many pre-tests and post-tests as you can using the skills lab resources.
Attendance Policy Class participation is expected and will be assigned a grade through quizzes, presentations, and participation in discussion. Another measure of participation comes from evidence of progress toward completion. This is evaluated through timely submissions of assignments.
Academic Honesty Cheating and plagiarism are acts of academic dishonesty. They refer to the use of unauthorized books, notes, or otherwise securing help in a test; copying tests, assignments, reports, or term papers; representing the work of another as one's own; collaborating, without authority with another student during an examination or in preparing academic work; partial or complete use of another's work without giving proper credit; or otherwise practicing scholastic dishonesty. All students are expected to follow Merced College Academic Honesty Procedure. Each student is expected to refrain from acts of academic dishonesty and refuse to aid or abet any form of academic dishonesty. Refer to the RN Student Handbook for actions that may be taken.
Academic Help Assistance is available in various areas of concentration including math, writing skills, and study habits through the http://www.mccd.edu/academics/resourses/help.html. Students are encouraged to seek assistance early in the semester.
Accommodation in the Classroom If you have a verified physical, medical, psychological, or learning disability or perhaps you feel you may have one of these disabilities which impacts your ability to carry out assigned course work, please contact the Disabled Student Services (DSS) office. DSS staff will review your needs and determine what accommodations are necessary and appropriate. All information and documentation is confidential. DSS is located in the Lesher Student Services Bldg. Room 234, phone 384-6155. In Los Banos, DSS is located in Building A, phone 381-6423.
3 Introduction to the RN Program
Reference: RN Student Handbook
Objectives: In the classroom, clinical, and/or lab the student will:
• Differentiate the role of learner from the role of teacher and relate those roles to student behavior ./ With the instructor ./ With the client
• Explain the significance of health teaching and describe the student nurse as a "role mode" in the learning of health behaviors by clients. • Describe the philosophy and purpose of the Merced College R.N. program. = Explain the purpose and procedure of Student Grievance Policy. • Explain the concept of proactive learning and develop a process for becoming a proactive learner. • Discuss the integrative nature of the RN classes: ./ Nursing in Health & Illness I (REGN 15) ./ Pharmacology in Nursing Practice (REGN 18) • Discuss location of resources on websites ./ Clinical forms http://www.mccd.edu/alliedhealth/REGN/Forms.htm
• Specific Clinical Skills Objectives ./ Confirmed written order ..f Handwashing ./ Necessary equipment gathered ./ Allergies checked ./ Identification of Patient (must have armband, Allergy band, & patient number) ./ Appropriate communication & clear explanation of procedure to patient ./ Preparation for patient & unit ./ Patient privacy maintained ./ Proper positioning of patient, nurse, bed ./ Gloves worn and/or proper isolation technique maintained ./ Correct administration of medication or treatment ./ Patient positioning for comfort & safety ./ Correct collection, labeling and handling of specimens ./ Accurate charting
4 August 2013
I Monday I, TuesdayI I Wednesday I I Thursday Friday 1 2 - 3 •
5 6 7 8 9 10
11 12 13 • 14 15 16 17 RN-15 Skills RN-15 Skills ; Theory 0800-1000 . Theory 0800-1000 ; 0800-1600 0800-1600 AHC-124 AHC-124 AHC-131 AHC-140 History of nursing/ Professionalism/ Nursing Education Standards of "' Practice ' AT!- Critical Thinking Test/ Blackboard 1000- RN-15 Skills 1100 1300-1600 Computer Lab AHC-140 18 19 20 21 22 23 . 24; RN-15 Skills RN-15 Skills Theory 0800-1000 Theory 0800-1000 I 0800-1600 0800-1600 Legal/Ethical AHC-124 AHC-131 AHC-140 AHC-124 Culture/ Ethnicity
Math Test#1 AHC-124 RN-15 Skills 1300-1600 AHC-140 25 26 27 28 29 30 31 ' , RN-15 Skills RN-15 Skills Theory 0800-1000 Theory0800-1000 0800-1600 0800-1600 AHC-124 AHC-124 AHC-131 AHC-140 Spirituality Growth and Development
RN-15 Skills 1300-1600 AHC-140 September 2013
I I I Monday TuesdrY Wednesday Thursda.lf Friday 1 1 2 3 4 5 6 7 Holiday RN-15 Skills Theory0800-1000 Theory 0800-1000 0800-1600 AHC-124 AHC-124 AHC-140 Exam# 1 Documentation/ Communication/SBAR Math Test# 2 AHC-124 RN-15 Skills 1300-1600 AHC-140 8 9 10 11 12 13 14 RN-15 Skills RN-15 Skills Theory 0800-1000 Theory 0800-1000 0800-1600 0800-1600 AHC-124 AHC-124 AHC-140 AHC-140 Nursing Informatics Information Literacy Practical Sldlls Examination en AHC-140 (sign ups provided] 15 16 17 18 19 20 21 RN-15 Skills RN-15 Skills Theory 0800-1000 Theory 0800-1000 0800-1600 0800-1600 AHC-124 AHC-124 AHC-140 AHC-140 Nursing Process Critical Thinking/ Reasoning Math Test# 3 AHC-1241000-1100 RN-15 Skills 1300-1600 AHC-140 22 23 24 25 26 27 28 RN-15 Skills RN-15 Skills Theory 0800-1000 Theory0800-1000 0800-1600 0800-1600 AHC-124 AHC-124 AHC-140 AHC-140 Health Assessment/ Exam #2 Physical Assessment RN-15 Skills 1300-1600 AHC-140 29 30 RN-15 Skills . 0800-1600 AHC-140 October 2013
I Monday Wednesday Thursday Friday ~ ~~~ 1 2 3 4 5 RN-15 Skills Theory 0800-1000 Theory 0800·1000 0800-1600 · AHC-124 AHC-124 AHC-140 Safety . Personal Hygiene/ Asepsis/ Universal ' Precautions . RN- 15 Skills 1300-1600 · AHC-140 6 7 8 9 10 11 12 Theory 0800-1000 Theory 0800-1000 Clinical- Mercy/ AHC-124 AHC-124 AnberryI Los Banos Patient Education Sensory 0630-1700 Post~Conference perception/pain 1000-1300 13 14 15 16 17 18 19 Theory 0800-1000 Theory 0800·1000 Clinical· Mercy/ AHC-124 AHC-124 An berryI Los Banos Activity I Exercise Nutrition 0630-1700 Post-Conference 1000·1300 20 21 22 23 24 25 26 Theory 0800·1000 Theory 0800-1000 Clinical· Mercy/ AHC-124 AHC-124 AuberryI Los Banos Oxygenation Exam# 3 0630-1700 Post-Conference 1000-1300 27. 28 29 30 31 Theory0800·1000 Theory0800-1000 AHC-124 AHC-124 Bowel Elimination Urinary Elimination Math Test#4 AHC-124 Post-Conference 1000·1300 November 2013
I I Monday ' Tuesday Wednesday Thursday Friday ' 1 2 Clinical- Mercy/ Anberry/ Los Banos 0630-1700
3 4 5 6 7' 8 9 Theory 0800-1000 Theory 0800-1000 Clinical- Mercy I AHC-124 . AHC-124 AnberryI Los Banos Fluids Electrolytes 0630-1700
Post-Conference 1000-1300 10' 11 12 13 14 15 16. Theory 0800-1000 Theory 0800-1000 Clinical- Mercy/ co AHC-124 AHC-124 Anberry/ Los Banos Acid-base balance Exam#4 . 0630-1700
Post-Conference 1000-1300 17 18 19 20 21 22 23 Theory 0800-1000 Theory 0800-1000 Clinical- Mercy I AHC-124 AHC-124 AnberryI Los Banos Psychosocial health and Loss, Grief, Dying 0630-1700 illness
Post-Conference 1000-1300 24. 25 26 27 28 29 30 Theory 0800-1000 Holiday Holiday AHC-124 Stress and Adaptation
Post- Conference 1000-1300 December 2013
Monday , Tues~ay Wednesday Thursdail'I Friday 1 2 3 4' 5 6 7 Theory 0800-1000 Theory 0800-1000 ' No Class/ Start of Finals AHC-124 AHC-124 :Week Sleep and Rest Exam#S
Post~Conference ATI- Fundamentals 1000-1300 Testing 1000-1100 Computer L 15 16 17 18 19 20 21 22 23 24 25 26 28 29 30 31 Week 1- Monday. Tuesday. Wednesday, Thursday Monday- 8/12 I & 0 Charting Abbreviations- Handout PPE Hand washing Tuesday- 8/13 V/5 Bed making Restraints Bath i ng/Pe rica re/Shavi ng Oral Hygiene Wednesday-8/14 ATI Critical Thinking Thursday- 8/15 Oral suction ROM/Positioning Week 2- Monday. Tuesday. Thursday Monday- 8/19 Transfers Hot/Cold Application Ostomy care Ace wrap/Abdominal binder Enemas 10 Tuesday- 8/20 Ace wrap/Abdominal binder Oral Airway, Oxygen mask & cannula, Ambu bag D/CIV LPAT, KATZ & Mini mental Thursday- 8/22 Glucoscan Foley insertion/condom cath Week 3- Monday, Tuesday. Thursday Monday- 8/26 Medication administration PO & topical NG tube suction maintenance, G-tube feedings, G-tube Medications SC: withdrawing from vial mixing insulin, syringe safety, Lovenox/Heparin Tuesday- 8/27 Intradermal injections D/Cfoley Catheter care Clean/Sterile urine specimen Thursday- 8/29 Medication administration IM Medication Administration- Nasal & Inhalers 11 Week 4-Tuesday, Thursday (Monday- Holiday) Tuesday- 9/3 Medication administration IM Medication Administration- Nasal & Inhalers Medication administration- Otic, Optic, Rectal, Vaginal Dry sterile dressing/wet-dry dressing Thursday 9/5 Discuss clinical paperwork Week 5 - Monday, Tuesday, Thursday Monday 9/9 Check-off/orientation Tuesday- 9/10 Check-off/orientation Thursday- 9/12 Practical Examination 12 Merced College REGN -15 Course Description Credit: 9 units 2-Way Co-requisite: REGN-18 This course presents basic concepts that provide the foundations upon which homeostasis is maintained in adults and/or children. Common threads integrated throughout the program are initiated: Nursing Process, Nutrition, Pharmacology, Developmental Levels, Cultural Diversity, Communication, and Professional Role. Required Text As indicated in text Jist located in the RN website. Course Pedagogy Students are guided through lessons using a combination of PowerPoint presentations, brief audio and/or video, activities, assignments, quizzes, exams, and readings (text, website, articles, etc.). Topics are explored through weekly instructor and/or student-led discussions. Method of Evaluation Students are evaluated through assignments, presentations, quizzes, and exams. Assignments are due by the beginning of class on the date due. Late work receives a 10% deduction. Quizzes are unannounced and intended to explore the student's grasp of main topics. Exams are divided into four unit review exams. Exam items are primarily multiple choice with some multiple select, matching, diagram selection and short answer questions. Students have 50 minutes in which to complete the exams. Missed exams receive 10% reduction in score. Students are required to schedule a make-up time for a missed exams with the Allied Health Office within one week or forfeit points for that exam .. A final exam is administered covering the content of the semester. Following each of the four unit exams, students are divided into small groups to repeat the exam for a group score. This process allows students an opportunity to discuss the material and develop a deeper understanding. *ATI Nurse logics must be completed prior to first examination. Evaluation Percent Grading is as follows: 90 - 1OO=A, 80 - 89=8, Assignments and Quizzes/AT! Nurse logics 5 75 -79=C, 74- 60=0, <60=F Exams (5) 75 Final Exam 20 Students must achieve 75% or greater to pass Total Points 100 this course in the RN Program. Tentative Schedule The schedule provided is intended to give you a guideline for study. Actual times may vary according to the needs of the class and any unforeseen problems. Assignment dates are provided in advance to allow students to work ahead and identify problems in advance of the due dates. 13 Clinical Principles 1. The student nurse is held to the same level of accountability as a professional nurse in the performance of nursing duties. 2. A high degree of personal maturity is a prerequisite for the nurse before she/he practices nursing. 3. The health team has representation from all practitioner groups, and its members work interdependently and collaboratively in offering services distinctive to its profession. 4. Due to the expanding professional role from one of direct and limited care of the ill patients to involving extensive planning and coordination of total patient care, the nurse is increasingly more vulnerable to legal action. 5. Each nursing practitioner is expected to uphold and adhere to the code of their professional society. 6. Nurses enter into partnerships with patients (nurse-patient relationship) and as such, exist to assist the patient in meeting the needs as defined by the patient. Nurses are concerned primarily with the health of the individual rather than disease. Confidentiality • Confidentially is the duty to respect privileged information. • It is a basic ethical principle that ensures a client's privacy. • You are legally bound to keep client information confidential. • It is grounds for dismissal from the program to not adhere to confidentiality. • Read you RN Student Handbook! • Avoid discussing the client's condition with anyone who is not involved in the case. • Do not share patient's records with anyone outside of the hospital. • Do not tell information the client does not want told, even if you think others have the right to know. (e.g., patient with AIDS and family does not know but will be caring for the patient). You can't tell the family, just encourage patient to discuss it with them. • Be careful walking in hallways, not talking about patients. • If you have a question about your duty/ethical responsibility with a patient, please ask the instructors! 14 Course Student Learning Outcomes and Competencies The following course student learning outcomes and competencies represent the overall behaviors the student is to accomplish by the end of the course. They will build throughout the program to cuhninate in the program student learning outcomes and competencies. The individual weeky units taught in the classroom specify the specific content to be taught. As that content is taught it should be connected to the course student learning outcomes and competencies; this puts the weeldy "lesson" content into the bigger perspective of your curriculum strucuture. The same is hue for the clinical experience. Therefore, the clinical evaluation tool (CET) is developed based on these course student learning outcomes and competencies. Inclnded with the CET are clinical activities for each competency that provide students an opportunity to demonstrate their ability to achieve that particular competency. Tllis provides validity to the CET. Grading rubrics are used for each activity so all faculty are grading students using the same criteria and all students are aware of the criteria used to grade them. This provides reliability to the CET. Grading rubrics are included, but faculty should review these and revise if they believe the expected level of behaviors should be higher or lower than indicated. Students keep all the activities for the course in a 3-ring binder known as a clinical activity portfolio. Each of the 6 course outcomes can be divided into sections with a page divider then all the activities for the competencies for each of the outcomes are contained in the section for each that outcome. Some of the activities may be completed as students provide traditional patient care. However, some of them may be carried out as the only assignment for the day. Often two students work together on an activity then discuss their findings in postconference. It is most helpful to complete these clinical activities during clinical time with feedback from the faculty during clinical time. Tllis promotes active learning in the context of the environment and the patient. Students can be asked to conect any enors while still in the environn1ent where the information resides and with the faculty available for feedback and discussion. Please feel free to add, delete, or revise any of the clinical portfolio activities. Adapted from ©20 12, Linda Caputi, Inc. 15 Nursing 15: Foundations of Nursing Registered Nursing 15 (Foundations of Nursing) focuses on foundational concepts necessary for safe, patient-centered nursing care to a diverse patient population while integrating legal and ethical responsibilities of the nurse. Introduces critical thinking applied to nursing, the nursing process, diversity, and communication techniques used when interacting with patients and members of the interdisciplinary team, and applies evidence-based nursing practice. Includes acquisition of basic nursing skills. Application oflmowledge and skills occurs in the nursing skills laboratory and a variety of acute and long-term care clinical settings. Registered Nursing 15 Course Outcomes 1. Provide quality, safe, patient-centered nursing care at the basic level. 2. Identify the nurse's role in collaborative relationships with members of the interdisciplinary team. 3. Demonstrate critical thinking/clinical reasoning when providing basic nursing care to patients from diverse backgrounds. 4. Identify the role of leadership for the purpose of providing and improving patient care. 5. Identify simple examples of information management and how they are used in the clinical environment. 6. Explain how professional standards, and legal and ethical principles apply to safe, quality, patient-centered nursing care. Registered Nursing 15 Course Competencies 1. Provide quality, safe, patient-centered nursing care at the basic level. • Conduct at a basic level a comprehensive and focused physical, behavioral, psychological, spiritual assessment eliciting patient values, experiences, and expressed needs. e Plan at a fundamental level holistic, patient-centered care that reflects psychosocial integrity, physiological integrity, and health promotion and maintenance within a variety of health care systems. o Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. • Demonstrate at a fundamental level the application of psychomotor skills for the efficient, safe, and compassionate delivery of patient care. • Deliver care within expected timeframe. • Monitor at a fundamental level patient outcomes, including interpretation of assessment data and appropriate follow-up, to evaluate the effectiveness of nursing interventions. • Identify quality measures when evaluating effects of nursing interventions appropriate to the care environment. • Describe factors that create a culture of caring for the patient and the patient's support network. • Communicate effectively with the patient and the patient's support network. • Communicate effectively when reporting care provided and evaluation data including appropriate handoff reports. Adapted from ©20 12, Linda Caputi, Inc. 16 • Provide at a fundamental level appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and level of health literacy. • Evaluate effectiveness of patient teaching. 2. Identify the nurse's role in collaborative relationships with members of the interdisciplinary team. • Explain effective communication teclmiques that produce positive professional working relations. • Interact with members of the health care team to plan patient care and evaluate progress toward patient outcomes. • Identify the nurse's role in decision making related to patient care. • Identify examples of conflict resolution. • Identify own role as a member of the interdisciplinary healthcare team. • Describe ways in which team functioning impacts safety and quality improvement. 3. Demonstrate critical thinking/clinical reasoning when providing basic nursing care to patients from diverse backgrotmds. • Identify how critical thinking/clinical reasoning is used to approach patient care. • Demonstrate at a fundamental level tolerance for ambiguity and unpredictability and its effect on patient care. • Interpret and correctly implement physician and interprofessional orders. • At the fundamental level anticipate risks and predict and manage potential complications. o Use the nursing process to malce decisions about patient care. 4. Identify the role of leadership for the purpose of providing and improving patient care. • Identify how the delegation process is used in the healthcare setting. • Describe how the individualized plan of care is implemented in the healthcare setting. • Describe the differences in the provision of patient care among various healthcare settings. • Describe the effect of the nursing leadership in the healthcare setting. • At the fundamental level, describe the quality improvement processes in the clinical setting used to effectively implement patient safety initiatives and monitor performance measures. • Apply the National Patient Safety Goals to patients in the clinical setting and identify any areas in need of improvement. 5. Identify simple examples of information management and how they are used in the clinical environment. • Maintain organizational and client confidentiality. • Discuss skills used in the clinical area to implement clinical information systems for safe nursing practice. • Explain the role of information teclmology in improving patient care outcomes and creating a safe care environment. Adapted from ©20 12, Linda Caputi, Inc. 17 6. Explain how professional standards, and legal and ethical principles apply to safe, quality, patient-centered nursing care. • Apply rules and regulations that authorize and define professional nursing practice. • Demonstrate professional standards of moral, ethical, and legal conduct. • Assume accountability for own behaviors, including a recognition for when to ask for assistance. • Practice within the parameters of individuallmowledge and experience. • Identify limits and boundaries of therapeutic, patient-centered care. Adapted from ©2012, Linda Caputi, Inc. 18 Nursing 15: Foundations of Nursing: Mid-term and Final Clinical Evaluation Tool- Scoring Sheet Student: ______Clinical Faculty:------ S =Satisfactory Nl =Needs Improvement U =Unsatisfactory (Must be Satisfactory by final evaluation) Midterm Grade Final Grade Course Outcome s NI u s u Evaluation Tool I. Provide quality, safe, patient-centered nursing care at the basic level. a, b. Concept Map a. Conduct at a basic level a comprehensive and focused physical, behavioral, c. Patient Preferences Tool psychological, spiritual assessment eliciting patient values, experiences, and d. Psychmotor Skills Reflect expressed needs. Sheet b. Plan at a fundamental level holistic, patient-centered care that reflects e. No tool for this competency; .... psychosocial integrity, physiological integrity, and health promotion and faculty observation . Adapted from ©2012, Linda Caputi, Inc. I. Evaluate effectiveness of patient teaching. 2. Identify the nurse's role in collaborative relationships with members of the a. Interprofessional interdisciplinary team. Communicatin Interaction Sheet a. Explain effective communication techniques that produce positive c. Basis for Making Decisions professional working relations. b, e, f: Teamwork Impacting b. Interact with members of the healthcare team to plan patient care and Safety and Quality Improvement evaluate progress toward patient outcomes. Measures c. Identify the nurse's role in decision making related to patient care. d. Conflict Resolution on the d. Identify examples of conflict resolution. Clinical Unit e. Identify own role as a member of the interdisciplinary health care team. f. Describe ways in which team functioning impacts safety and quality improvement. 3. Demonstrate critical thinking/clinical reasoning when providing basic nursing a, c, e: Patient Care/Nursing care to patients from diverse backgrounds. Process Critical Thinking a Identify how critical thinking/clinical reasoning is used to approach patient Activity care. b. Parameters for Patient Care b. Demonstrate at a fundamental level tolerance for ambiguity and d. Predict and Manage Potential unpredictability and its effect on patient care. Complications c. Interpret and correctly implement physician and interprofessional orders. d. At the fundamental level anticipate risks and predict and manage potential complications. e. Use the nursing process to make decisions about patient care. 4. Identify the role of leadership for the purpose of providing and improving a. Identifying Delegation patient care. Responsibilities a. Identify how the delegation process is used in the health care setting. b, c. Implementing the b. Describe how the individualized plan of care is implemented in the Individualized Plan of Care healthcare setting. d. Nursing Leadership and Safe, c. Describe the differences in the provision of patient care among various Quality Patient Care healthcare settings. e. Tool for I, g: Quality d. Describe the effect of the nursing leadership in the healthcare setting. Measures e. At the fundamental level, describe the quality improvement processes in the f. National Patient Safety Goal clinical setting used to effectively implement patient safety initiatives and Activity monitor performance measures. f. Apply the National Patient Safety Goals to patients in the clinical setting and identify any areas in need of improvement. 5. Identify simple examples of information management and how they are used in a. Organizational and Patient the clinical environment. Confidentiality Observation Adapted from ©2012, Linda Caputi, Inc. a. Maintain organizational and client confidentiality. Rubric b. Discuss skills used in the clinical area to implement clinical information b, c. Technology is More than systems for safe nursing practice. Charting c. Explain the role of information technology in improving patient care outcomes and creating a safe care environment. 6. Explain how professional standards, and legal and ethical principles apply to a, b, e. Moral, Ethical, Legal, safe, quality, patient-centered nursing care. and Professional Standards a. Apply rules and regulations that authorize and define professional nursing Observation Rubric practice. c, d. Accountability Observation b. Demonstrate professional standards of moral, ethical, and legal conduct. Rubric c. Assume accountability for own behaviors, including a recognition for when to ask for assistance. d. Practice within the parameters of individual knowledge and experience. e. Identify limits and boundaries of therapeutic, patient-centered care. Additional Comments: Signatnres: Midterm Evaluation Date: ______Final Evaluation Date: ------Student______Stndent______Faculcy ______Faculcy ______ The following pages contain the Clinical Activicy Portfolio Tools for Foundations of Nursing, Course Stndent Learning Outcome#!. Adapted from ©2012, Linda Caputi, Inc. Course Student Learning Outcome #1, Competencies: a. Conduct at a basic level a comprehensive and focused physical, behavioral, psychological, spiritual assessment eliciting patient values, experiences, and expressed needs. b. Plan at a fundamental level holistic, patient-centered care tbat reflects psychosocial integrity, physiological integrity, and health promotion and maintenance within a variety of healtbcare systems. Tool: Concept Map "' Adapted from ©20 12, Linda Caputi, Inc. .\s1ettlliE!III D:lla Xuning lnten~tieru md KuninE: C.u~ - Ntmil!f Jnm.-~tiC!l! !llld Nnniru: err~ - Pbysiolllglt:~llntegr{ly. He.td-ID-loe .tues!fmeor --ill!U of (OIItl!m (diet, ellmln;~.tinn, hydntion, eft-) .\sseument D:na .-\.ueumenrData S.tfe CareEnrironmenl: Psytbo5oclal In Iegrlty: S:tfeey .\ge-re!:ued usk:J Culture li----.-1 Aniube dtrit~ Spiritual Pret:11ution1 All-r.Dinctire Religion Hulth Prmolion & l[ainfenance: DLte1u Fiodingt Tr-eatmenb. Nun~ intm.~tiel!! and fluids NuningCare Xucing lntetYentions. md Nun~C.m- Grading Rubric for the Concept Map Performance s NI u Level Lists collected data in Identifies?. 5 Identifies 3-4 IdentifY less than 2 appropriate section of objective/subjective data within objective/subjective data objective/subjective data within concept map. each appropriate areas within each appropriate each appropriate basic need area Identifies nursing Writes?. 3 nursing Writes?. I nursing Unable to identifY nursing interventions specific interventions specific to each intervention specific to interventions for all areas to each area area each area Adapted from ©2012, Linda Caputi, Inc. Course Student Learning Outcome #1, Competency: c. Deliver compassionate, patient-centered, evidence-based care that respects patient and fanlily preferences. Tool: Patient Preferences Tool Use own textbook and agency guidelines to compare and contrast care provided versus text and agency recommendations. Activity: • Access your textbook. • Access any available agency source for clinical guidelines regarding your patient's condition. • Review the patient's chart to see how closely the care prescribed relates to that in your textbook and in the agency's clinical guidelines. • Note if there are variances and fmd our why there are variances. Key recommendations of Comparison to Adherence to agency Reasons for variance Nen guidelines textbook: guidelines or variation (Pt preference, physical or other conditions) Adherence or variation? Medications: Tests/Lab work Activity/Health behaviors Adapted from ©2012, Linda Caputi, Inc. Grading Rubric for Patient Preferences Tool Performance Level s NI u Compares care to Clearly compares care to Scant comparison of Unable to compare care to textbook and textbook and agency care witb that in the textbook and agency guidelines. agency guidelines. guidelines. textbook and agency guidelines. Identifies variances Clearly identifies variances Scantly identifies Unable to identify variances based on patient based on patient preferences. variances based on based on patient preferences. _]JI"eferences. patient preferences. Adapted from ©2012, Linda Caputi, Inc. Course Student Learning Outcome #1, Competency: d. Demonstrate at a fundamental level the application of psychomotor skills for the efficient, safe, and compassionate delivery of patient care. Psychomotor Skills Reflection Sheet Date Skill How I believe I performed. Ways I can improve. Adapted from ©2012, Linda Caput~ Inc. Rubric for the Psychomotor Skills Tool Performance Criteria s NI u Psychomotor Skills Clearly describes Able to describe Descriptions of Tool: how the how the performance of Demonstrates competent psychomotor skill psychomotor skills psychomotor and safe nursing care. was performed, was performed but skills are scant evaluates self with limited insight and unorganized. ..., performance, and to problems on self Does not offer 00 offers 2 ways for performance. ways to improve improvement. Offers one way to future improve performance. . performance. Faculty Notes Related to Acceptable Performance of Psychomotor Slcill: Adapted from ©2012, Linda Caputi, Inc. Course Student Learning Outcome #1, Competency: f. Monitor at a fundamental level patient outcomes, including interpretation of assessment data and appropriate follow-up, to evaluate the effectiveness of nursing interventions. Signs and Symptoms Critical Thinking Tool Lists the signs and symptoms you noted on your assessment of your patient. What diagnostics tests were completed relative to these manifestations? What medical treatments/interventions were implemented to treat these manifestations? (Include medications.) What nursing interventions were implemented to treat these manifestations? Any manifestations not being addressed? What will you do about them? Which of the above indicate the interventions were/were not effective? Adapted from ©2012, Linda Caputi, Inc. Signs and Symptoms Grading Rubric Performance Level s NI u l. Identifies In depth explanation of Explanation includes Brief explanation of the signs/symptoms and the signs/symptoms and some but not all of the signs/symptoms and laboratory infonnation laboratory infunnation signs/symptoms and laboratory infonnation related to the patient's related to the patient's laboratory infonnation related to the patient's condition including the condition including the related to the patient 1s condition including the medical and nursing medical and nursing condition including the medical and nursing treatments for the disease. treatments for the disease. medical and nursing treatments for the disease. treatments for the disease. "'0 2. IdentifY In depth explanation of Explanation includes Brief explanation of the manifestations not manifestations not some but not all of the manifestations not addressed by present addressed by present manifestations not addressed by present nursing and/or medical nursing and/or medical addressed by present nursing and/or medical interventions. interventions. nursing and/or medical interventions. interventions. 3. Identifies patient In depth explanation of Explanation includes Brief explanation of the evaluation data used to patient evaluation data some but not all ofthe patient eva! uation data determine if interventions used to detennine if patient evaluation data used to detennine if were/were not effective. interventions were/were used to detennine if interventions were/were not effective. interventions were/were not effective. not effective. Adapted from ©20 12, Linda Caputi, Inc. Course Student Learning Outcome #1 Competency: g. Identify quality measures when evaluating effects of nursing interventions appropriate to the care environment. Quality Measures The quality measures for this assignment include safety and fall risi{S. 60 Second Assessment for Fall Risl{S The overall purpose of this assignment is to: • Assess safety and fall risks each time student enters a patient's room • Identify safety hazards in the patient environment that will cause harm or could potentially lead to harm • Perform risk factor interventions when applicable ~ Directions: Enter the patient's room and observe the patient and the environment for up to 60 seconds while reviewing the following questions. After the 60 second assessment, discuss your findings with your clinical instructor and perform interventions (when applicable) to reduce fall risks. Tubes and Lines Your Findings Does the patient have any tubes or an IV? Does the patient need these tubes or IV, if so, why? Are the tubes tangled or crossing along the patient? Equipment Your Findings • If an IV pole is present, is the stand steady and easy to maneuver? • Are the side rails up? Does the upper or all four need to be raised up? Adapted from ©2012, Linda Caputi, Inc. • Is the height of the bed in the lowest position? • Are the bed brakes on? • Is the call light within reach? • Are any bed/exit alarms on? Why or why not? Environmental Y onr Findings Is the bed side table and patient's immediate belongings/essentials within reach of the patient? Is the floor wet or is clutter or debris present? What else about the environment could lead to a problem for the patient? Patient Safety Survey Your Findings Does the patient have non-skid slippers on? Has the patient previously been identified as a fall risks? Does the patient have a fall risks identification armband on? Is a fall risk sign and/or symbol on the patient's door or at the bedside? Is the patient confused, disoriented, or visually impaired? Overall,_what are your safety concerns with Your Findings this patient? Do you need to report any risks factors or problems? If so, to whom? How would you manage the risk factors and problems, if any? Adapted from ©20 12, Linda Caputi, Inc. After your 60 second assessment is complete answer the following questions: What are the tools used for fall risk measurement on this unit? Grading Rubric for the 60 Second Safety Assessment Performance Level s NI u Safety and fall risk assessment Thoroughly conducts a Explanation includes some Brief explanation of a safety safety and fall risk but not a complete safety and fall risk assessment. assessment and fall risk assessment. Identified safety hazards Identifies all potential Explanation includes some Scant list of potential and and actual safety but not all potential and actual safety hazards. hazards. actual safety hazards. Identified interventions to prevent harm to patient Identifies all Identifies some but not all Scant list of interventions to interventions to prevent interventions to prevent prevent harm to patient. harm to patient. harm to patient. Adapted from ©20 I2, Linda Caputi, Inc. Course Student Learning Outcome #1 Competency: h. Describe factors that create a culture of caring for the patient and the patient's support network. QSEN Activity Related to Patient-Centered Care and Caring Caring Model o Introduce yourself and explain your role in the patient's care for the day o Call the patient by his or her preferred name; talk with the patient's support network if members are present. o Sit with the patient for at least five minutes per shift to discuss the day's care and milestones to cross (best done at the beginning of the shift) o Use touch, such as a handshalce or touch on the arm, or exhibit a caring behavior that is unique to your own personality and approach o Most important, demonstrate commitment to the care and improvement of the patient's life and hospital stay. The following sample interview questions will provide the patient with an opportunity to express their agenda, concerns and lead to more patient centered care. Questions for patient (5 minute sit down) 1. What would you like to see happen today? 2. How would you describe your hospitalization? Is there anything that could be done to malce it better? 3. What should nursing students know about what it's like being a patient in the hospital? After Your "Sit down": Discuss what happened during your sit down with the patient/patient's support network. Adapted from ©20 12, Linda Caputi, Inc. Describe factors from your time with the patient/patient's support network that demonstrate a culture of caring. Grading Rubric for the Caring Activity Perfonnance Level s Nl u Able to discuss what happened during sit down. Thoroughly discusses Explanation includes some Scant explanation of what what happened during but not a complete account happened during sit down. sit down. of what happened during sit down. Able to relate factors from sit down that Thorough discussion of Explanation includes some Scant explanation of factors demonstrated a culture of caring. factors from sit down but not all factors from sit from sit down that that demonstrated a down that demonstrated a demonstrated a culture of culture of caring. culture of caring. caring. Adapted from ©20 12, Linda Caputi, Inc. Course Student Learning Outcome #1 Competency: i. Communicate effectively with the patient aod the patient's support network. Patient Interaction Sheet Date Commnnication How the How the Communication was Techniques Used Communication was Ineffective Ways I can with Patient Effective improve. Adapted from ©20 12, Linda Caputi, Inc. Rubric for Patient Interactions Sheet Performance Criteria s NI u Identizy effective Clearly describes Describes Descriptions of communication skills to communication communication communication between use when interacting between self and between self and self and patient are scant with patients, significant patient. Identifies patient. Identifies and unorganized. Does not others, and health care non therapeutic non therapeutic offer ways to improve team members. communication communication future interactions. used. Offers at two used. Offers only ways to improve one way to future interactions improve future listing specific interactions listing therapeutic specific therapeutic communication communication techniques. techniques. Adapted from ©20 12, Linda Caputi, Inc. Course Student Learning Outcome #1 Competency: j. Communicate effectively when reporting care provided and evaluation data including appropriate handoffreports. Tool: SBAR patient report Situation Patient Name: Include basic Code Status: demographics about VS: your patient; name, Outputs: ethnicity. !Vs/fluids: age, gender, and Abnonnal/concerns: pertinent infonnation about the patient's condition/situation. Include patient preferences. "' Background Pertinent background infonnation affecting the patient's current condition. patient's admitting diagnosis, hospital day, medical history that might Other history that is also present and may or may not affect current condition but needs to be considered. complicate her current admission, any data about what has led up to any problems the patient is currently experiencing. Assessment Mental Status: Signs and Alert and oriented symptoms that are Confused related to patient's Cooperative or non-cooperative diagnosis, including Agitated or combative Adapted from ©20 12, Linda Caputi, Inc. vital signs, 02 Sats, Lethargic but conversant and able to swallow and any other Stuporous and not talking clearly and possibly not able to swallow pertinent Comatose. Eyes closed. Not responding to stimuli assessment data. Skin: Should correlate Warm and dry with the Pale information on the Mottled signs and symptoms Diaphoretic tools. Extremities are cold Extremities are warm Patient is or is not on oxygen: L!min or oxygen for min(hrs) Pulse ox reading What you think the problem is: The pt is Stable, unstable, _getting worse Recommendations I suggest that you: Include what you have done and the Any diagnostic labs/test needed/pending: patient's response. Need to notify the physician, primary healthcare provider: Adapted from ©2012, Linda Caputi, Inc. SBAR Communication Rubric Performance Criteria s NI u Informs responsible staff Clearly completes the Clearly completes portions of the SBAR The SBAR report is scant member of patient status SBAR report for a report for a patient. Some criteria do not and/or unorganized. It is patient. All criteria are have documentation and/or and are not difficult to understand. documented on and are easy to read. easy to understand and follow. Adapted from ©20 12, Linda Caputi, Inc. Course Student Learning Outcome #1 Competency: k. Provide at a fundamental level appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and level of health literacy. 1. Evaluate effectiveness of patient teaching. Patient Teaching Tool (Fundamentals) Refer to your signs and symptoms tool. What teaching needs to be completed regarding any of the concerns noted on the signs and symptoms tool? What modifications will you need to make related to your teaching methods based on the patient's developmental stage, age, culture, preferences, and level of health literacy? Adapted from ©2012, Linda Caputi, Inc. Was your teaching effective? If so, how do you !mow? If no, how do you know and what will you do? Adapted from ©20 12, Linda Caputi, Inc. Signs and Symptoms Grading Rubric Performance Level s NI u Identifies teaching needs. In depth explanation of Explanation includes Brief explanation of patient's learning needs. some but not all of patient's learning needs. patient's learning needs. Explains modifications to In depth explanation of Explanation includes Brief explanation of teaching based on necessary modifications some but not all necessary modifications patient's developmental to teaching based on necessary modifications to teaching based on stage, age, culture, patient's developmental to teaching based on patient's developmental spirituality, patient stage, age, culture, patient's developmental stage, age, culture, preferences, and level of spirituality, patient stage, age, culture, spirituality, patient health literacy. preferences, and level of spirituality, patient preferences, and level of health literacy. preferences, and level of health literacy. health literacy. Evaluates effectiveness of In depth explanation of Explanation includes Brief explanation of the teaching. effectiveness of teaching. some but not all issues issues related to the related to the effectiveness of teaching. effectiveness of teaching. Adapted from ©20 12, Linda Caputi, Inc. Course Student Learning Outcome #2: Identify the nurse's role in collaborative relationships with members of the interdisciplinary team. The following pages contain the Clinical Activity Portfolio Tools for Foundations of Nursing , Course Student Learning Outcome#2. Adapted from ©2012, Linda Caputi, Inc. Course Outcome #2 Competency: a. Explain effective communication techniques that produce positive professional working relations. Tool: Interprofessional Communication Interaction Sheet Information Date Today I talked Collected to Evaluate Communication Communication Ways I can improve with Progress Toward Techniques Used that were Techniques Used to Produce Positive members of the Achievement of Effective that were Ineffective Professional healthcare team. Patient Outcomes World~~g Relations. Healthcare team member: Healthcare team member: Healthcare team member: Adapted from ©2012, Linda Caputi, Inc. Rubric for lnterprofessional Communication Interaction Sheet Performance Criteria s NI u Identify effective and ineffective Clearly describes communication Describes communication Descriptions of communication skills to use when between self and a member of the between self and a communication between interacting with members of the healthcare team. Identifies member of the health care self and other healthcare healthcare team. effective and ineffective team. Identifies effective providers are scant and communication techniques used. and ineffective unorganized. Does not offer Offers at two ways to improve communication ways to improve future future interactions listing specific techniques used. Offers interactions. techniques. only one way to improve future interactions. Information collected related to Able to identify patient outcomes Identifies some but not all Unable to identify patient evaluation of achievement of and how collected information patient outcomes and able outcomes and how patient outcomes. relates. to relate some collected collected information information to them. relates. Adapted from ©2012, Linda Caputi, Inc. Course Outcome #2 Competency: c. Identify the nurse's role in decision making related to patient care. Basis for Making Decisions Activity: Locate the staff job description for the RN. Review the California Board of Registered Nursing's scope of practice Review the ANA's Standards ofPractice Identifies how these three documents relate to the nurse's role in making decisions related to patient care. Complete the following: RN Job Description related to Describe the RN's role from the Describe the RN's role as outlined decision making for patient care. Nurse Practice Act related to in the ANA's Standards of Practice Decision malting by me or the RN decision malting for patient care. related to decision malting for based on professional standards. patient care. Adapted from ©20 12, Linda Caputi, Inc. Rubric for Basis for Making Decisions Performance Criteria s NI u Describe the basis for decision Clearly describes basis for Provides a superficial Unable to describe the basis making for the RN based on the decision making for the RN based description for the basis for decision making for the job description, nurse practice act, on the job description, nurse for decision making for RN based on the job and the ANA Standards of practice act, and the ANA the RN based on the job description, nurse practice practice. Standards of practice. description, nurse act, and the ANA Standards practice act, and the ANA of practice. Standards of practice. Relates decisions made in patient Clearly relates decisions made in Provides a superficial Unable to relate decisions care to the job description, nurse patient care to the job description, relationship for decisions made in patient care to the practice act, and the ANA nurse practice act, and the ANA made in patient care to job description, nurse Standards of practice. Standards of practice. the job description, nurse practice act, and the ANA practice act, and the ANA Standards of practice. Standards of]Jractice. Adapted from ©20 12, Linda Caputi, Inc. Course Outcome #2 Competency: d. Identify examples of conflict resolution. Tool: Conflict Resolution on the Clinical Unit Interview a Nurse and One Other Healthcare Provider to Ask Healthcare Professional Observe the Interactions of all What Conflicts did yon Observe Identity An Area of Conflict on How the Conflict was Resolved the Healthcare Professionals on and How were they Handled or the Unit the Unit Not Handled Two students can spend one day completing the above then reporting in postconference. Once the postconference activity occurs, students will complete the below each day: Identify a conflict on the unit and how it was resolved. What did you learn? Discuss with faculty or in postconference. Adapted from ©20 12, Linda Caputi, Inc. Rubric for Conflict Resolution Performance Criteria s NI u Conflict identified on the unit. Clearly describes a conflict on the Description of a conflict Unable to describe any unit. on the unit are vague and conflicts on the unit. unclear. Suggestions for how to resolve the Clearly and accurately describes Identifies some but not all Unable to describe conflict. solutions for resolving the possible solutions for solutions for resolving the identified conflict. resolving the identified identified conflict. conflict. "'0 Adapted from ©2012, Linda Caputi, Inc. Course Outcome #2 Competencies: b. Interact with members of the healthcare team to plan patient care and evaluate progress toward patient outcomes. e. Identify own role as a member of the interdisciplinary health care team. f. Describe ways in which team functioning impacts safety and quality improvement. Tool: Teamwork Impacting Safety and Quality Improvement Measures How are patients What is your How docs team What nursing How arc unit falls identified as being "at What screening What role as a member functioning sensitive quality and pressure ulcers risk for falls" & "at tools are used? prevention of the impact patient indicators arc used on tracl Two students will complete this activity in lieu of a patient care assigrunent, then report in postconference. After this postconference presentation all students will incorporate this activity into their daily patient care assigrunents by answering the following questions each day: 1. The prevention measures and precautions I'll implement include: Adapted from ©20 12, Linda Caputi, Inc. 2. My role on the interdisciplinary team related to these measures. 3. How team functioning impacts patient outcomes related to these safety and quality improvement measures. Rubric for Teamwork Impacting Safety and Quality Improvement Measures Performance Criteria s NI u Identifies prevention and Clearly describes prevention and Description of Unable to describe any precaution measures. precaution measures. prevention and precaution prevention and precaution measures are vague and measures. "' unclear. "' Identifies the nurse's role on the Clearly and accurately describes Identifies some but not all Unable to describe the interdisciplinary team related to the nurse's role on the roles of the nurse on the nurse's role on the quality and safety measures. interdisciplinary team related to interdisciplinary team interdisciplinary team quality and safety measures related to quality and related to quality and safety safety measures measures Describes how team functioning Clearly and accurately describes Identifies some but not all Unable to describe how impacts patient outcomes related to how team functioning impacts ways team functioning team functioning impacts these safety and quality patient outcomes related to these impacts patient outcomes patient outcomes related to improvement measures. safety and quality improvement related to these safety and these safety and quality measures. quality improvement improvement measures. measures. Adapted from ©2012, Linda Caputi, Inc. Course Student Learning Outcome #3: Demonstrate critical thinking/clinical reasoning when providing basic nursing care to patients from diverse backgrounds. The following pages contain the Clinical Activity Portfolio Tools for Foundations of Nursing, Course Student Learning Outcome#3. Adapted from ©20 12, Linda Caputi, Inc. Course Outcome #3 Competencies: a. Identify how critical thinking/clinical reasoning is used to approach patient care. c. Interpret and correctly implement physician and interprofessional orders. e. Use the nursing process to malce decisions about patient care. Tool: Patient Care/Nursing Process Critical Thinking Activity Note: Two students work through tllis activity over and over on one clinical day in place of a traditional patient care assignment. Patient Care Critical Thinldng Activity Answer the following: I. Patient information: Age: Reason for admission: Date of admission: Diagnostic Procedures: Surgical procedure: Diet: Activity: 2. Medications: Drug: Reason why it was prescribed: Therapeutic effects expected: Adverse effects to monitor: (Complete for all medications prescribed.) 3. Patient history: Important information from history: From the history, the most important data impacting this hospitalization is: 4. Diagnostic tests: Name of test: Why was this test ordered? (Complete for each test ordered.) 5. Problems occurring for this patient during the preceding 24 hours: How were the above problems handled? Adapted from ©20 12, Linda Caputi, Inc. Patient Care Critical Thinking Activity On a separate sheet of paper, answer the following: 6. What specific physician/healthcare provider orders relate to your care today and how will you implement those orders? 7. Was the physician called for any reason? If so, why? What information was gathered prior to notifYing the physician? What actions were taken? 8. Potential problems that could occur for this patient: Interventions to prevent the potential problems: 9. Look at the patient's nursing care plan: List the nursing diagnoses: Prioritize the nursing diagnoses: How did you determine the order of prioritization of the nursing diagnoses? What are the interventions for the top two nursing diagnoses? Prioritize those interventions: Which of these interventions can you delegate to an unlicensed person? IO. Look at the shift report sheets for the past 24 hours. Based on those report sheets, what is the MOST IMPORTANT nursing intervention for you "' to carry out this shift? II. Visit the patient and perform a two-minute head-to-toe assessment. 12. Based on your assessment reprioritize your nursing diagnoses and interventions if needed. If not, state why they remain the same. I3. If the physician came in at this moment and discharged this patient, what are the most important teaching instructions for this patient? I4. What if...... (Ask me to complete this question for you to answer.) Here the teacher poses a "What if' question based on the information the student collected. Reflection: Answer the following: 1. What did you learn from this experience? 2. How will you use those lessons learned when caring for patients in the future? Once the above activity is completed and discussed in postconference, each week students will complete the activity when planning care for their assigned patients and answer the above reflection questions. Adapted from ©20 I2, Linda Caputi, Inc. Rubric for Patient Care/Nursing Process Critical Thinking Activity Performance Criteria s NI u Completes all sections of the tool. Accurately completes all sections Able to complete some, Unable to complete all of the tool. but not all, all sections of sections of the tool. the tool. Identifies lessons learned from the Clearly identifies lessons learned Description oflessons Unable to describe any patient care tool. from the patient care tool. learned from the patient lessons learned from the care tool are scant. patient care tool. Discusses ways to use the lessons Clearly discusses ways to use the Superficially discusses Unable to discuss ways to U1 learned when caring for patients in lessons learned when caring for ways to use the lessons use the lessons learned C'l the future. patients in the future. learned when caring for when caring for patients in patients in the future. the future. Adapted from ©20 12, Linda Caputi, Inc. Course Outcome #3 Competency: b. Demonstrate at a fundamental level tolerance for ambiguity and unpredictability and its effect on patient care. Tool: Parameters for Patient Care What are the patient's vital signs: Blood pressure: Pulse: Respirations: Temperature: What were the highs and lows for the past 24 hours? What is the patient's activity level? What medications is the patient taking that affect the vital sign readings? What medical/nursing interventions is the patient experiencing that may affect the patient's vital signs? What other factors are influencing this patient's vital sign readings? How low can each of the readings go before you would intervene? Give your rationale. How high can each of the readings go before you would intervene? Give your rationale. Adapted from ©20 12, Linda Caputi, Inc. Rubric for Parameters for Patieut Care Performance Criteria s NI u Able to identifY all factors Clearly identifies all factors Description of all factors Unable to identifY all ' influencing the patient's vital signs. influencing the patient's vital influencing the patient's factors influencing the signs. vital signs is scant. patient's vital signs. co Able to identifY reasonable Clearly identifies reasonable Superficially discusses Unable to discuss "' parameters for vital signs and parameters for vital signs and reasonable parameters for reasonable parameters for rationales. rationales. vital signs and rationales. vital signs and rationales Adapted from ©2012, Linda Caputi, Inc. Course Outcome #3 Competency: d. At the fundamental level anticipate risks, and predict and manage potential complications. Tool: Predict and Manage Potential Complications For each patient answer these questions based on the nursing theory presented to date: I. What are you on alert for today with this patient? 2. What are the important assessments to malce? "' 3. What complications may occur? What could go wrong? 4. What interventions will prevent complications? Students will use this same activity as they go through the program clinical courses. Faculty can then compare their answers from course to course to provide evidence of higher level thinking. Adapted from ©20 12, Linda Caputi, Inc. Rubric for Predict and Manage Potential Complications Performance Criteria s NI u Based on the nursing theory Clearly identifies complications Description of Unable to identij'y presented to date able to identij'y that may occur with patient's complications that may complications that may complications that may occur with condition. occur with patient's occur with patient's patient's condition. condition is scant. condition. 0'1 0 Based on the nursing theory Clearly identifies interventions to Superficially discusses Unable to discuss presented to date able to identij'y prevent complications. interventions to prevent interventions to prevent interventions to prevent complications. complications. complications. Adapted from ©20 12, Linda Caputi, Inc. Course Student Learning Outcome #4: Identify the role of leadership for the purpose of providing and improving patient care. The following pages contain the Clinical Activity Portfolio Tools for Foundations of Nursing, Course Student Learning Outcome#4. en..... Adapted from ©20 12, Linda Caputi, Inc. Course Outcome #4 Competency: a. Identify how the delegation process is used in the healthcare setting. Tool: Identifying Delegation Responsibilities Locate the staffjob descriptions for the RN, LVN, and certified nursing assistant. Bring a copy of the California Nurse Practice Act Complete the following: Job Descriptions/Comparison Observations about the Job Title Job Responsibilities Related Comparison with the Process of Delegation at this to the Delegation Process California Practice Act Agency One group of two students will complete this activity in lieu of a patient care assignment. Once the assignment is discussed in postconference all students will answer the following questions each day they care for patients: 1. What activities that you performed today could you delegate and to whom? Explain. 2. Did the RN delegate those activities? Why or why not? Adapted from ©20 12, Linda Caputi, Inc. Rubric for Identifying Delegation Responsibilities Performance Criteria s NI u Explanation of the patient care Clearly explains patient care Description of patient Unable to explain patient activities performed that can be activities performed that can be care activities performed care activities performed delegated to whom and rationale delegated to whom and rationale that can be delegated to that can be delegated to why. why. whom and rationale why whom and rationale why. is scant. Explanation about what the RN Clearly explains what the RN Superficially discusses Unable to discuss what the delegated and did not delegate. delegated and did not delegate what the RN delegated RN delegated and did not and why. and did not delegate and delegate and why. why. Adapted from ©20 12, Linda Caputi, Inc. Course Outcome #4 Competencies: b. Describe how the individualized plan of care is implemented in the healthcare setting. c. Describe the differences in the provision of patient care among various healthcare settings. Tool: Implementing the Individualized Plan of Care C omp1eItth£11 e e o owme;: Observations about the Members ofthe Nursing Care Job Responsibilities Related Comparison with Other Process of Providing Team to Implementing the Healthcare Settings Individualized Care in this Individualized Plan of Care Healthcare Settine;. Adapted from ©2012, Linda Caputi, Inc. Rubric for Implementing the Individualized Plan of Care Performance Criteria s NI u Explanation of implementation of Clearly explains how the Description of how the Unable to explain how the the individualized plan of care. individualized plan of care is individualized plan of individualized plan of care implemented. care is implemented is is implemented . scant. Comparison with other health care Able to compare the Superficially discusses Unable to discuss the settings. implementation of the the individualized plan of individualized plan of care individualized plan of care with care with the process in with the process in another "' the process in another healthcare another healthcare healthcare setting. setting. setting. Adapted from ©20 12, Linda Caputi, Inc. Course Outcome #4 Competency: d. Describe tbe effect oftbe nursing leadership in the healtbcare setting. Tool: Nursing leadership and safe, quality patient care Read about the different types of nursing leadership styles in your fundamentals book. Identify the nursing leadership positions in tbe institution. Observe the interactions of the nurse leaders on tbe unit then complete the table. Activity: 1. Identify tbe nursing leadership positions in tbe institution. 2. Locate the job descriptions for those positions. 3. Observe the interactions of the nurse leaders on tbe unit then complete tbe table. 4. This table can be completed over tbe course of a few weeks. Complete the following: Observed Interactions Explain the effect of nursing leadership on Job Title Major Responsibilities with Others: (list, ie, RN, improved patient safety and quality care. CNA, etc.) Adapted from ©2012, Linda Caputi, Inc. Rubric for Nursing Leadership and Safe, Quality Patient Care Performance Criteria s NI u Provides accurate observations Clearly provides accurate Explanation of Unable to explain about the interaction of the nursing observations about the observations about the interactions of the nursing staff. interactions of the nursing staff. interactions of the nursing staff. staff is scant. Explain the effect of nursing Able to explain the effect of Superficially discusses Unable to discuss the effect leadership on improved patient nursing leadership on improved the effect of nursing of nursing leadership on safety and quality care. patient safety and quality care. leadership on improved improved patient safety and patient safety and quality quality care. care. Adapted from ©20 12, Linda Caputi, Inc. Course Outcome #4 Competency: e. At the fundamental level, describe the quality improvement processes in the clinical setting used to effectively implement patient safety initiatives and monitor performance measures. Tool: See tool for Outcome 1, Competency g. Identify quality measures when evaluating effects of nursing interventions appropriate to the care environment. Quality Measures en co Adapted from ©2012, Linda Caputi, Inc. Course Outcome #4 Competency: f. Describe the use of National Patient Safety Goals in the clinical setting to maintain a safe environment for all patients. Tool: National Patient Safety Goal Activity Two students spend one day assessing the environment and at least 3 patients. Their goal is to look at the environment and these patients from the perspective of the Joint Commission's Patient Safety Goals. Answer the following questions. Students may use additional paper for each patient. Report in postconference and discuss with fellow students. 1. What precautions should the nurse talce relative to each safety goal for each patient? 2. For each patient, is there a safety goal that is the most important for each of these patients? 3. What information about each of these patients is most important to communicate to the nurse on the next shift? 4. Can the SBAR form be used for this environment or should it be revised? If so, how would you revise it? 5. What factors about the environment indicate these safety goals are being met? 6. Gap Analysis: What factors about the environment indicate a need for change so the safety goals can be met? Once students have completed this assignment, they incorporate this information into their daily care of patients and answer these questions: 1. What NPSG most applied to this patient? 2. Are the safety goals being met? If not, what will you do to correct the situation? Adapted from ©20 12, Linda Caputi, Inc. Rubric for National Patient Safety Goal Activity Performance Criteria s Nl u Identifies the NPSG most Clearly identifies the NPSG most Scantly identifies the Unable to identizy the applicable to this patient. applicable to tl1is patient. NPSG most applicable to NPSG most applicable to this patient. this patient. Explains if the safety goals are Able to explain if the safety goals Superficially explains if Unable to explain if the .... being met, and if not, explains are being met, and if not, explains the safety goals are being safety goals are being met, 0 what to do to correct the situation. what to do to correct the situation. met, and if not, and if not, explains what to superficially explains do to correct the situation. what to do to correct the situation. Adapted from ©2012, Linda Caputi, Inc. Course Student Learning Outcome #5: Identify simple examples of information management and how they are used in the clinical environment. The following pages contain the Clinical Activity Portfolio Tools for Foundations of Nursing, Course Student Learning Outcome#S. Adapted from ©20 12, Linda Caputi, Inc. Course Outcome #5 Competency: a. Maintain organizational and patient confidentiality. Tool: Organizational and Patient Confidentiality Observation Rubric Read the agency's policy related to organizational and patient confidentiality. Observation Rubric Behavior Satisfactory Needs Improvement Unsatisfactory Demonstrates adherence to Applies the agency policy in Requires supporting cues when Unable to apply the agency's agency policy related to the care setting with no applying the agency's policy. policy in the clinical setting. organizational and patient supporting (verbal/physical) confidentiality. cues. Provide examples of how you satisfactorily met this competency each day you cared for patients: Day 1: Day2: Day 3: Day 4: Day 5: Day6: Adapted from ©20 11, Linda Caput~ Inc. Course Outcome #5 Competencies: b. Discuss skills used in the clinical area to implement clinical information systems for safe nursing practice. c. Explain the role of information technology in improving patient care outcomes and creating a safe care environment. Tool: Technology is more than Charting This informatics worksheet relates to technology used on the unit including computer charting, but all other types ofteclmology as well. Type of Technology How the Technology Who Accesses the How does the technology (list all technology used: computer is Used Technology contribute to safe, quality charting, IV pumps, pulse oximeters, etc.) care? Reflections: 1. Summarize your impression of the importance of technology in patient care. 2. How will you use technology to provide safe patient care? Adapted from ©20 12, Linda Caput~ Inc. Rubric for Technology is More than Charting Performance Criteria s NI u Summarize your impression of the Summary reflects information Scantly summarizes Unable to summarize importance of technology in gatl1ered on tl1e tool. information gathered on information gathered on the patient care. the tool. tool. Discuss how will you use Able to discuss how technology is Superficially discusses Unable to discuss how technology to provide safe patient used to provide safe patient care. how technology is used to technology is used to care. provide safe patient care. provide safe patient care. Adapted from ©20 12, Linda Caputi, Inc. Course Student Learning Outcome #6: Explain how professional standards, and legal and ethical principles apply to safe, quality, patient-centered nursing care. The following pages contain the Clinical Activity Portfolio Tools for Foundations of Nursing, Course Student Learning Outcome#6 . ..... "' Adapted from ©20 12, Linda Caputi, Inc. Course Outcome #6 Competencies: a. Apply rules and regulations that authorize and define professional nursing practice. b Demonstrate professional standards of moral, ethical, and legal conduct. e. Identify limits and boundaries of therapeutic, patient-centered care. Tool: Moral, ethical, legal, and professional standards observation rubric This tool is used to demonstrate application of and moral, ethical, legal, and professional conduct in the care of aging patients in the long-term care setting. Observation Rubric Behavior Satisfactory Needs Improvement Unsatisfactory Demonstrates application of the Applies professional standards and Applies some but not all professional Unable to apply professional ..... professional standards of moral, moral, ethical, and legal conduct in standards and moral, ethical, and legal standards and moral, ethical, and legal O"l ethical, and legal conduct in the care the care of patients with no supporting conduct in the care of patients and conduct in the care of patients. of patients. (verbal/physical) cues. requires supporting (verbal/physical) cues. Provide examples of how you satisfactorily met these competencies each day you cared for patients: Day 1: Day2: Day3: Day 4: DayS: Day6: Adapted from ©20 12, Linda Caputi, Inc. Course Outcome #6 Competencies: c. Assume accountability for own behaviors, including a recognition for when to ask for assistance. d. Practice within tbe parameters of individuallmowledge and experience. Tool: Accountability Observation Rubric Behavior Satisfactory Needs Improvement Unsatisfactory Assumes accountability for personal Assumes accountability for personal Assumes some accountability for Unable to assume accountability for and professional behaviors, including and professional behaviors, including personal and professional behaviors, personal and professional behaviors, a recognition of when to ask for a recognition of when to ask for including a recognition of when to ask including a recognition of when to ask assistance and recognizing limits of assistance and recognizing limits of for assistance and recognizing limits for assistance and unable to identifY own individual knowledge and own individual knowledge and of own individual knowledge and limits oflrnowledge and experience. experience. experience with no supporting experience requires supporting (verbal/physical) cues. (verbal/physical) cues. Provide examples of how you satisfactorily met these competencies each day you cared for patients: Day 1: Day2: Day3: Day4: Day 5: Adapted from ©20 12, Linda Caputi, Inc. Merced College Associate Degree Nursing Program Registered Nursing 15: Foundations of Nursing Course Syllabus 4 hours lecture, 15 hours skills lab/clinical Registered Nursing 15 (Fmmdations of Nursing) focuses on foundational concepts necessary for safe, patient-centered nursing care to a diverse patient population while integrating legal and ethical responsibilities of the nurse. Introduces critical thinking applied to nursing, the nursing process, diversity, and communication techniques used when interacting with patients and members of the interdisciplinary team, and applies evidence-based nursing practice. Includes acquisition of basic nursing skills. Application of knowledge and skills occurs in the nursing skills laboratory and a variety of acute and long-term care clinical settings. Registered Nursing 15 Course Outcomes I. Provide quality, safe, patient-centered nursing care at the basic level. 2. Identify the nurse's role in collaborative relationships with members of the interdisciplinary team. 3. Demonstrate critical thinking/clinical reasoning when providing basic nursing care to patients from diverse backgrounds. · · · 4. Identify the role of leadership for the purpose of providing and improving patient · care. 5. Identify simple examples ofinfom1ation management and how they are used intiie''' clinical environment. 6. Explain how professional standards and legal and ethical principles apply to safe, quality, patient-centered nursing care. Registered Nursing 15 Course Competencies I. Provide quality, safe, patient-centered nursing care at the basic level. ~ Conducts at a basic level a comprehensive and focused physical, behavioral, psychological, spiritual assessment eliciting patient values, experiences, and expressed needs. • Plans at a fundamental level holistic, patient-centered care that reflects psychosocial integrity, physiological integrity, and health promotion and maintenance withina . , variety of healthcare systems. · · · • Delivers compassionate, patient-centered, evidence-based care that respects patient and family preferences. • Demonstrates at a fundamental level the application of psychomotor skills for the efficient, safe, and compassionate delivery of patient care. • Delivers care within expected timeframe. 78 • Monitors at a fundamental level patient outcomes, including interpretation of assessment data and appropriate follow-up, to evaluate the effectiveness of nursing interventions. • Identifies quality measures when evaluating effects of nursing interventions appropriate to the care environment. • Describes factors that create a culture of caring for the patient and the patient's support network. • Communicates effectively with the patient and the patient's support network. • Conm1unicates effectively when reporting care provided and evaluation data including appropriate hand off reports. • Provides at a fundamental level appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and level of health literacy. • Evaluates effectiveness of patient teaching. 2. Identify the nurse's role in collaborative relationships with members of the interdisciplinary team. • Explains effective communication techniques that produce positive professional working relations. • Interacts with members of the health care team to plan patient care and evaluate progress toward patient outcomes. • Identify the nurse's role in decision making related to patient care. • Identifies examples of conflict resolution. • Identifies own role as a member of the interdisciplinary healthcare team. • Describes ways in which team functioning impacts safety and quality improvement. 3. Demonstrate critical thinking/clinical reasoning when providing basic nursing care to patients from diverse backgrounds. · • Identifies how critical thinking/clinical reasoning is used to approach patient care. • Demonstrates at a fundamental level tolerance for ambiguity and unpredictability and its effect on patient care. • Interprets and correctly implements physician and interprofessional orders. • At the fundamental level anticipates risks and predicts and manages potential complications. • Uses the nursing process to make decisions about patient care. 4. Identify the role of leadership for the purpose of providing and in1proving patient · care. • Identifies how the delegation process is used in the healthcare setting. • Describes how the individualized plan of care is implemented in the healthcare setting. • Describes the differences in the provision of patient care among various healthcare settings. • Describes the effect of the nursing leadership in the healthcare setting. • At the fundamental level, describes the quality improvement processes in the clinical setting used to effectively implement patient safety initiatives and monitor performance measures. 79 • Applies the National Patient Safety Goals to patients in the clinical setting and identifies any areas in need of improvement. 5. Identify simple exan1ples of infom1ation management and how they are used in the clinical environment. • Maintains organizational and client confidentiality. • Discusses skills used in the clinical area to implement clinical infommtion systems for safe nursing practice. • Explains the role of information teclmology in improving patient care outcomes and creating a safe care environment. 6. Explain how professional standards and legal and ethical principles apply to safe, quality, patient-centered nursing care. • Applies rules and regulations that authorize and define professional nursing practice. • Demonstrates professional standards of moral, ethical, and legal conduct. • Assume accountability for own behaviors, including a recognition for when to ask for assistance. • Practices within the parameters of individual knowledge and experience. • Identifies limits and boundaries of therapeutic, patient-centered care. Registered Nursing 15 Topical Outline 1. Fundamental concepts of quality, safe, patient-centered, evidence-based nursing care 2. Collaboration and communication teclmiques in nursing practice 3. Critical thinking and clinical reasoning applied to nursing practice 4. Introduction to leadership and management concepts/principles 5. Introduction to information technology 6. Introduction to professionalism and standards of practice This topical outline will be applied to weekly content. Required Texts 1 Deglin, J. & Vallerand, A. (2009). Davis's drug guide for nurses, (ll h ed.). Philadelphia: FA Davis. Dillon, P. M. (2007). Nursing health assessment: Clinical pocket guide, (2nd ed.). Philadelphia: F. A. Davis. Malarkey, L. & McMorrow, M. E. (2005). Sounder's nursing guide to laboratOIJI & diagnostic tests. St. Louis: Elsevier Saunders. Potter, P.A., & Perry, A. G. (2013). Fundamentals ofNursing. (8th ed.). St. Louis: Elsevier Whitehead, D. K., Weiss, S. A., & Tappen, R. M. (2010). Essentials ofnursing 1 leadership and management. (5 h ed.). Philadelphia: F. A. Davis. 80 Unit 1 Introduction to Nursing Purpose: Tins unit introduces the student to the profession of nursing, professional guidelines, and what a nurse does in practice. Basic nursing care is the foundation for all of nursing. hnportant topics include measuring vital signs, implementing standard precautions, meeting hygiene needs, evidence-based practice, quality improvement, caring, and collaboration. The one major area that all nurses and other health care professionals must be always nlindful of is safety. Safety is also discussed in this unit and the student is introduced to the National Patient Safety Goals used in healthcare environments. Learning Objectives and Course Outcomes Specific student leaming objectives appear at the beginning of each chapter. These will be used as the focus of the content. The specific content is then related to the following course outcomes: 1. Provide quality, safe, patient-centered nursing care at the basic level. 2. Identify the nurse's role in collaborative relationsllips with members of the interdisciplinary tean1. 3. Identify the role of leadership for the purpose of providing and improving patient care. 4. Identify simple examples of information management and how they are used in the clinical environment. 5. Explain how professional standards and legal and ethical principles apply to safe, quality, patient-centered nursing care. Unit 1: Major Topics 1. Professional nursing practice a. History of nursing and nursing education (Ch 1-5) b. Legal and ethical responsibilities (Ch 22 & 23) c. Professionalism and standards of practice (Ch 1-5) 2. Diversity a. Culture and et1micity (Ch 9) b. Spirituality (Ch 35) c. Growth & development (Ch 11-14) 3. Communication in nursing, collaboration, teamwork (Ch 24 & 26) a. Documentation b. Handoff conmmnication!SBAR reporting 4. Nursing informatics- an introduction a. Computers in healthcare a. Review of computers as tools, various application types for productivity b. Etllical/legal/social issues around computer use b. Clinical Paperwork 81 c. Infom1ation Literacy I) Accessing health resources on the Internet 2) Evaluating web sites and resources as primary and secondary, popular vs. scholarly 3) Electronic databases Nursing Skills Laboratory The student will spend the week's laboratory time in the nursing lab at the college. Basic nursing skills will be discussed, demonstrated, and practiced. These skills include: I. Hand washing 2. Universal precautions 3. Sterile Equipment & Sterile Gloving 4. Vital signs 5. Measuring intake and output 6. Charting I&O and vital signs 7. Practice documentation Practice the above skills in the nursing skills laboratory. Return demonstration for vital signs. Reqnired Reading 1. Potter & Peny, Chapters 1-5; 9; 11-14; 22-26; 35. 2. http://www.qsen.org/news.php#joint-commission-tacldes-miscommunication-among caregJvers 3. http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniquefo rCommunicationASituationa!BriefingModel.htm 4. Sections of the California Nurse Practice Act that governs nursing practice. 82 Unit2 The Nursing Process, Critical Thinking Health History and Physical Assessment Purpose: This unit begins with the nursing process. Then, the first step of the nursing process, assessment, is considered in more depth with an overview of taking a health history and conducting a physical assessment. The student will continue to build skill in assessment by addressing in more depth both the history and the physical with each unit in Nursing 15 and all subsequent nursing course throughout the nursing program. Evidence-based nursing practice is also introduced. Learning Objectives and Course Outcomes Specific student learning objectives appear at the beginning of each chapter. These will be used as the focus of the content. The specific content is then related to the following course outcomes: I. Provide quality, safe, patient-centered nursing care at the basic level. 2. Demonstrate critical thinking/clinical reasoning when providing basic nursing care to patients from diverse backgrounds. · Unit 2: Major Topics I. The Nursing Process (Ch 16-20) a. Evidence-based nursing practice (Ch 5) 2. Critical thinking; clinical reasoning (Ch 15) 3. Health assessment (Ch 16 & 30) a. Taking a health history b. Conducting a physical assessment Nursing Skills Laboratory 1. Taking a health history 2. Basic physical assessment Required Reading I. Potter & Perry, Chapters 5; 15-20; 30. 83 Unit3 Safety Personal Hygiene Patient Teaching Purpose: Safety has become a primary focus ofhealthcare institutions. It is also a major concept in the nursing curriculum at Merced College. This unit covers basic information about ensuring safety when providing quality patient care. The second major area of content relates asepsis and universal precautions, both important safety measures, when leanling about providing personal hygiene. Inherent in all nursing care is patient teaclling. Patient teaclling is both formal and informal. Learning Objectives and Course Outcomes Specific student learning objectives appear at the begimling of each chapter. These will be used as the focus of the content. The specific content is then related to the following course outcomes: 1. Provide quality, safe, patient-centered care. 2. Demonstrate critical thinking/clinical reasoning when providing basic nursing care to patients from diverse backgrounds. 3. Explain professional standards, and legal and etllical principles as they relate to safe, quality, patient-centered nursing care Unit 3: Major Topics 1. Safety in the environment (Ch 27-29) 2. Personal Hygiene/Asepsis/Universal Precautions (Ch 39) 3. Patient Teaching (Ch 25) Nursing Skills Laboratory I. Sterile Equipment & Sterile Gloving 2. Bed making 3. Positioning 4. Bed Batlling 5. Transfers 6. Lifts Required Reading • Potter & Perry, Chapters 25; 27-29; 39. • The Joint Comnlission's website on National Patient Safety Goals for acute care and long-term care settings: http://www.j ointcommission.org/standards_ information/npsgs.aspx • Quality and Safety Education for Nurses: qsen.org 84 Unit4 Supporting Physiological Functioning: Sensory Perception Pain Movement Purpose: Tliis unit is the first of several that discusses the nurse's role in supporting physiological functioning by introducing the student to three major areas of patient need- sensory perception, pain, and movement. Problems with any of these three can place the patient at risk for injury; therefore, safety is a primary concern when studying sensory perception, pain, and movement. Learning Objectives and Course Outcomes Specific student learning objectives appear at the beginning of each chapter. These will be used as the focus of the content. The specific content is then related to the following course outcomes: I. Provide quality, safe, patient-centered nursing care at the basic level. 2. Demonstrate critical thinking/clinical reasoning when providing basic nursing care to patients from diverse backgrounds. 3. Explain how professional standards and legal and et!Iical principles apply to safe, quality, patient-centered nursing care. Unit 4: Major Topics 1. Sensory perception (Ch 49) 2. Pain (Ch 43) 3. Activity and exercise (Ch 38 & 47) Nursing Skills Laboratory: 1. Mobility 2. Ambulation 3. Wheelchair 4. Gurney 5. ROM 6. Restraints Required Reading • Potter & Perry, Chapters 38; 43; 47; 49. 85 Unit5 Supporting Physiological Functioning: Nutrition, Oxygenation, Elimination, Fluids, Electrolytes, and Acid-Base Balance -· Purpose: This unit continues the discussion of supporting normal physiological functioning addressing nutrition, oxygenation, elimination, fluids, electrolytes, and acid-base balance. These discussions provide a framework and basis for higher level courses that discuss the nurse's role in caring for patients with alterations in these physiological processes. Learning Objectives and Course Outcomes Specific student learning objectives appear at tbe beginning of each chapter. These will be used as the focus of the content. The specific content is then related to the following course outcomes: 1. Provide quality, safe, patient-centered nursing care at the basic level. 2. Demonstrate critical thinking/clinical reasoning when providing basic nursing care to patients from diverse backgrounds. 3. Explain how professional standards and legal and ethical principles apply to safe, quality, patient-centered nursing care. Unit 5: Major Topics 1. Nutrition/Diet Therapy (Ch 44) 2. Oxygenation (Ch 40) 3. Bowel Elimination (Ch 46) 4. Urinary Elimination (Ch 45) 5. Fluids (Ch 41) 6. Electrolytes (Ch 41) 7. Acid-base balance (Ch 41) Nursing Skills Laboratory 1. Catheterization 2. Gavage, lavage NG Feedings 3. Enemas 4. 02 Therapy 5. Airways 6. Suctioning (non-sterile) Required Reading • Potter & Perry, Chapters 40-41; 44-46. 86 Unit 6 Supporting Psychosocial Functioning Purpose: Tlus unit discusses the nurse's role in supporting psychosocial functioning by introducing the student to major factors affecting psychosocial health. Support systems are also introduced in tins unit as a means for assisting patients to cope psychologically witl1 various illnesses and situations they encounter. Problems witl1, or lack of, these support systems can place the patient at risk for ilmess and injury. Learning Objectives and Course Outcomes Specific student learning objectives appear at the beginning of each chapter. These will be used as the focus oftl1e content. The specific content is tl1en related to the following course outcomes: 1. Provide quality, safe, patient-centered nursing care at the basic level. 2. Demonstrate critical tl1inking/clinical reasoning when providing basic nursing care to patients from diverse backgrounds. · 3. Explain how professional standards and legal and etl1ical principles apply to safe, quality, patient-centered nursing care. Unit 6: Major Topics 1. Psychosocial healtl1 and illness (Ch 6; 10; 33) 2. Loss, grief, and dying (Ch 36) 3. Stress and adaptation (Ch 37) 4. Sleep and rest (Ch 42) Nursing Skills Laboratory 1. N Monitoring, IV DC, Tube Maintenance 2. Application of Heat and Cold Required Reading • Potter & PeiTy, Chapters 6; 10; 33; 36-37; 42. 87 Unit 7 Wound Care Advanced Concepts of Nursing Purpose: . Tllis unit addresses the final physiological topics for the course, that of wound care and : first aid then health promotion. It then turns the student's attention to higher level concepts of nursing theory and research, leadersllip and management, delegation, and quality improvement. Learning Objectives and Course Outcomes Specific student learning objectives appear at the begim1ing of each chapter. These will be used as the focus of the content. The specific content is then related to the following course outcomes: 1. Provide quality, safe, patient-centered nursing care at the basic level. 2. Identify the nurse's role in collaborative relationsllips with members of the interdisciplinary tean1. 3. Demonstrate critical tllinking/clinical reasoning when providing basic nursing care 'to patients from diverse backgrounds. 4. Identify the role of leadership for the purpose of providing and improving patient care. Unit 7: Major Topics 1. Wound Care and First Aid Measures (Ch 48) 2. Nursing theory and research; evidence-based nursing (Ch 4-5) 3. Leadersllip and management (Ch 21) 4. Quality improvement (Ch 6) Nursing Skills Laboratory: 1. Bandages 2. TEDS 3. Binders & Dressings Required Reading • Potter & Perry, Chapters 4-6; 21; 48. • Whitehead, Weiss, & Tappen, Chapters 9, and 10 • http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/ PatientSafetyQuality/Research- Measurement/The-National-Database/Nursing Sensitive-Indicators_1.aspx 88 Student Clinical Objectives I. Nursing Process Assessment • Establish preparation following review of chart, care plan, and textbooks. Be able to convey the information in both verbal and written formats.** • Be able to explain with assistance: ** ./ the relationship between the client's course of treatment and nursing care needs . ./ nursing implications of normal lab, and diagnostic tests . ./ oral medications and nursing implications. Nursing Diagnosis • Select nursing diagnoses on the basis of data collection. Planning • Collaborate with staff, client, and faculty in establishing short-term client goals and interventions utilizing standardized care plans. Implementation • Implement interventions in response to client needs. • Demonstrate 1'' semester nursing skills. ** • Complete skills check requirements (green) for semester. ** • Administer medications competently. ** Evaluation • Determine the effects of nursing interventions on the status of the client. II. Leadership & Teamwork • Establish priorities in planning, organizing, and completing basic care according to the needs of one assigned client. ** Ill. Communication • Communicate verbally and in writing, assessments and client responses to care . •• • Report promptly abnormal or unclear information to appropriate health care team member and instructor. This includes absences. ** IV. Client Education • Demonstrate basic interviewing skills when informing the client about his health status. • Assess clients understanding of course of treatment and nursing care. V. Professional Accountability • Is prepared for clinical activities and aware of objectives to be accomplished. ** • Utilize and integrate theoretical knowledge in delivering client care. ** • Demonstrate the ability to problem solve and use the nursing process. ** • Practice within the ethical and legal framework of nursing, including client confidentiality. ** • Work within established school/agency goals and policies. ** • Recognizes own interactive behavior and use constructive criticism and suggestions for improving nursing practice. ** • Provide for physical and psychological safety of client. ** ** Critical Elements 89 Critical Elements Level I A. Overriding Critical Elements- Failure of an overrding area will result in termination and failure of the particular skill being tested. This criterion is applied to every skill. 1. Adherence to agency and Merced College RN Student Policy. (Merced College RN Student Policy is primary). a. Standard Precautions: 1) Applies standard/universal precautions to all procedures. 2) Recognizes appropriate barrier precautions for potential exposure. 3) Physical Well-being: Any action or inaction on the part of the student which threatens the client's physical well-being. 4) Checks the physician's order when applicable. 5) Identifies the client. 6) Maintains a safe environment. 7) Assessment and reassessment of client. 8) Uses equipment safely and appropriately. 9) Knows emergency procedures and equipment in clinical setting. 2. Emotional Well-being: Any action or inaction on the part of the student which fosters the client's emotional well-being; a. Introduces self. b. Explains procedure and client's role. c. Provides privacy. d. Maintains professional caring role, i.e., communication. 3. Medical Asepsis: a. Protects self from contamination (i.e., personal protective equipment). b. Protects client from contamination (i.e., handwashing). c. Disposes of contaminated material in designated containers. d. Confines contaminated material to contaminated area. 4. Documentation: a. Documents nursing action and client response in a timely manner. 5. Teaching Learning: a. Assesses barriers to learning. b. Provides teaching based on client learning needs. c. Evaluates client response and documents. B. Application of the Nursing Process Incorporating Nursing Judgment 1. Assesses the client on an ongoing basis using a systematic data collection approach to determine the client's current health status and evaluate present and post coping patterns. 2. Prepares in advance for each clinical experience. 3. Completes a physical assessment on all clients across the lifespan. 4. Plans client care needs based on assessment findings and care priorities. 5. Develops a written care plan on each client. 6. Implements client care. 7. Evaluates client response to care. 90 C. Skill Specific Critical Elements- Failure of a skill specific critical element will result in termination and failure of a particular skill being evaluated. 1. Charting: a. Observes legal requirements of charting. b. Applies the nursing process in charting. c. Records information pertinent to the client's condition and nursing care. 2. Medication Administration: The administration of drugs by any route. a. Identifies drug incompatibilities and allergies. b. Identifies correct landmarks. c. Follows the Rights: 1) Right patient; 2) Right drug; 3) Right route; 4) Right time; 5) Right dose; 6) Right documentation; 7) Right action/purpose; 8) Right form; 9) Right response; 1D) Verifies allergies. d. Verbalizes precautionary measures before administration, including anticipated side effects, drug interactions, and nursing implications. e. Performs appropriate assessments and reassessments. f. Uses equipment safely and appropriately. g. States rationale for correct antidote. h. Assesses client knowledge of medication and provides appropriate instruction. 3. Neuro Check: a. Assesses and reassesses level of consciousness and orientation. b. Evaluates motor response. c. Evaluates sensory response. 4. Fluid Assessment: a. Follows the elements in item C2 for medication administration. b. Site Care: 1) Insures patency. 2) Follows agency policy for site care. 3) IV Site Assessment every hour and prn .. 4) Documents site care. 5. Intake and Output: a. Monitors, records, and reports intake and output. 6. Mobility: a. When moving or positioning client, maintains proper body alignment and self and client. b. Observes safety regarding equipment when moving or positioning client. c. Evaluates nerve and blood supply to affected area (e.g., neuro-circulation checks). 7. NG Tube/Gastrostomy Tube: a. Feeding 1) Assesses and reassesses for correct placement. 2) Checks residuals every 2- 4 hours and prn. 3) Secures tube. 91 4) Flushes tube before and after medication administration. b. Skin Care: 1) Assesses and Reassesses skin integrity. 2) Washes with soap and water unless contraindicated. 3) Rinses and dries all areas. c. Decompression 1) Assesses and reassesses correct placement. 2) Assures correct suction level. 3) Assures the patency of the NG Tube. d. Irrigation: The introduction and return of irrigant. 1) Uses correct solution at appropriate temperature. 2) Controls flow (rate and volume) of solution. 8. Oxygenation: a. Positions client to facilitate respirations. b. Assures correct oxygen delivery. c. Skin Care: 1) Assesses and reassesses skin integrity. 2) Washes with soap and water unless contraindicated. 3) Rinses and dries all areas. 9. Surgical Asepsis-Sterile Technique: a. Maintains sterile field. b. Applies principles of sterile technique throughout the procedure. 10. Urinary Catheter: a. Applies Sterile Technique: 1) Maintains sterile field. 2) Applies principles of sterile technique throughout the procedure. b. Assesses and reassesses proper placement. 11. Vital Signs: a. Measures records and reports accurately: 1) +/-0.2 degrees for temperature 2) +/-2 mm Hg for blood pressure 3) +/-2 beats/minute for apical pulse 4) +/-1 respirations/minute 12. Wound Care: a. Maintains medical asepsis b. Maintains surgical asepsis-sterile technique 13. Blood Glucose Monitoring: a. Uses equipment correctly and efficiently. b. Cleanses client's finger per policy. c. Dons clean gloves. d. Collects adequate blood sample and assure homeostasis. 14. Written Care Plan: a. Every client will have a care plan based on the nursing process. The student will develop and/or update the care plan based on client data and assessment. 15. Pain Management: a. Assesses the client's pain on a scale of 1-10 (0 = no pain, 10 = pain). b. Informs the client of possible pharmaceutical and non-pharmaceutical methods of pain control. c. Encourages client to participate in goal setting of pain management. d. Evaluates and documents interventions and client's ongoing response. 92 16. Subcutaneous Medication Administration: a. Follows all the guidelines set forth in item C2. 17.1ntramuscular Medication Administration: a. Follows all the guidelines set forth in item C2. 18. Surgical Asepsis/Sterile Technique: a. Maintains sterile field. 19. Naso-pharyngeal and oropharyngeal suction: a. Provides adequate oxygenation. b. Verifies patency of suction and appropriate level of suction. c. Inserts catheter only to pharyngeal area. d. Maintains a patent airway. e. Fosters physical well-being. 20. Ostomy Care: a. Assess and reassesses skin integrity. b. Cleans skin and changes pouch when leaking. c. Applies bag and wafer correctly. d. Maintains integrity of the system by emptying when 1/3-2 full, and or client request. e. Monitors output. f. Assesses and reassesses stoma. g. Monitors input and output. 93 Important Student's Note Please Do Not Expect to perform a return demonstration unless you have viewed the associated videos and CO's and practiced the assigned skill several times to the point of mastery. You and another student will practice and sign off each other's checklist indicating successful practice of this skill. You will be expected to perform the skills with a level of expertise and competency equal to that performed by employable RN's. You and your instructors are Legally Liable for the level-of-care given to patients in the clinical setting. After successfully completing the objectives of the return demonstration, the instructor or mentor will sign and date your performance checklist and initial your performance checklist and initial your check-off book. These cards are used by your clinical instructors each week prior to assignments of patients. For example: if you have completed Hand Washing, Bed Making, but have not yet completed Bed Bath, you would be assigned a patient who is not ambulatory so assistance will be needed in bathing. You will not be assigned, nor should you accept an assignment that requires care beyond the level of procedures that you have completed in simulated in lab return demonstrations. Each time you perform a skill in the clinical area, you should document on your skill book and have your clinical instructor initial. When your instructors feel you are proficient in the skill, they will date and sign the far right column. With your instructors' permission, you may then be allowed to perform those skills independently. If you are unable to complete the objectives of the return demonstration satisfactorily, you will not be allowed to retest the same day. Open skills lab time is available each week for practice. Retesting will be done the following week as time allows, after the current week's skill has been completed. Retesting may be done by the lab instructor. Skills may not be performed in the clinical setting until competency is established in the lab. To summarize: Utilization of Simulated Lag for Return Demonstrations 1) View required media and/or instructor video demonstration and lecture (see syllabus for requirements). 2) Read pertinent theory for applicable principles. 3) Assemble equipment (bring skills supply bag) needed in laboratory and practice the procedure to master (either individually or with other students). Seek feedback from lab instructor if assistance is needed for clarification. 4) When you have successfully accomplished the demonstration, the instructor or mentor will sign and date your performance checklist and initial skills book. 5) If your return demonstration was not satisfactory, you will need to review specific areas (skills and/or knowledge) and then repeat the return demonstration with the instructor the following week. 6) There may be mini quizzes throughout the semester. Your grade will be based on criteria identified in your syllabus. Patient safety is deemed essential for each 94 and every procedure; any activity which places a patient in any kind of jeopardy, whether it is physical or psychological, is considered unsatisfactorv or failing. The following ground rules will be mutually acknowledged by the student and the mentor during the lab practicum: a. The burden of "proof of competency" rests with the student, not the evaluator. b. It is the student's responsibility to make ovett and explicit points being demonstrated. The mentor/instructor is not to cue, prompt, question, or remind the student during the demonstration. c. A mistake or error in performance may be corrected with penalty if: • The student recognizes and describes the error without prompting or cues and appropriately solves the problem. • The subsequent action is appropriate. • It is the student's responsibility to make sure that the mentor/instructor sees and hears the points the student is demonstrating or verbalizing. Feedback on Performance They suggest these guidelines: 1. Feedback is a gift. Consider others' reactions to be a gift, requiring a commitment and effort from the giver. 2. Giving feedback is a risk. So thank and reassure the giver. 3. Perception is a reality. Accept the impact of your behavior as the other's reality. You don't have to agree with it. 4. Distinguish impact and intent. Focus on being curious about your impact, not defensive about your presumed intent. 5. Lock for the "germ of truth". Adopt a "what can I learn from this?" posture. 6. Check your understanding. Paraphrase to verify what you hear and clarify anything you're unsure about. 7. Put the message in perspective. The feedback relates to just one aspect of your behavior, not your worth as a person. 8. Assume good intent. Assurne the giver values and wants to improve your relationship, even if the feedback expresses temporary dissatisfaction. 9. Separate consideration from action. Take time to think about what's been said before reacting. 10. Be responsible for yourself. You decide how much you can take, at what rate, and what you will do with the information. 11. First impressions are valid. Don't dismiss first impressions from new people because "they don't really know you yet". First impressions are important, and they provide some useful data you wouldn't otherwise have. 95 Written and Practice Skills Exam There is one Practical Skills Exam at week 5 prior to going to clinical. Students must pass Skills Exam with a minimum of 75%. Failure of the student to pass the Skills Exam with a minimum of 75% will result in the student not being permitted in the clinical area and MAY result in probation and/or dismissal from the RN Program. 96 Clinical Site Maps Annberry Rehabilitation Hospital 1685 Shaffer Rd. Atwater, CA 95301 209-357-3420 C2011 MapQuast, Inc. Use or directions and maps lssubjed to the MapCuesl Terms of Use. We make no guarantee of the accuracy of their con\en~ road conditions or route usability. You auume all risk of use. View Terms of Use 97 Mercy Medical Center 333 Mercy Ave. Merced, CA 95340 209-564-5000 @2011 MapQueat, Inc. Use or dlrecUona and maps Ia subject to the MepQueat Terms of Use, We make no guarantee of the occurocy of their content, road conditions or route usability. You assume all rlsk of use. View Terms of Use 98 Memorial Hospital Los Banos 520 West "I" St. Los Banos, CA 93635 209-826-0591 @2011 MapQuest, Inc. Use of directions and maps Ia subject to the MapCuost Terms or Use. We make no guarantee of the accuracy of their content, road conditions or route uaabl!lty. You BBBume all risk of use. View Terms of Use 99 Clinical Guidelines I. Your clinical prep varies based on the clinical site. After the fifth week, you will select your patient based on established criteria. II. After obtaining your patient assignment, you are to research the information you need in order to complete a nursing care plan for your client. When researching, you are to dress in business dress with a white Jab coat and your name tag visible. You must come prepared to clinical with the following: Patient Care Plan Pages 1 & 2 researched thoroughly and Signs & Symptoms with the primary and secondary diagnoses. To organize your thought for AM report you are to complete the AM Report. For each clinical day you MUST bring your Skills Booklet with you to be considered prepared for the clinical day. Failure to bring the Skills Booklet requires that you return home to get it or forfeit your clinical day and make up the time in the skills lab if possible. Ill. In the morning of each clinical day you must be prepared to give a morning report on your client from all the data you have gathered from your assessment. This report is not to exceed 5 minutes and consist of the clients name, age, sex, code, status, allergies, past medical history, current medical diagnosis, ADL status, nursing interventions for the signs and symptoms of the medical diagnosis, chosen NANDA nursing diagnoses in relation to signs and symptoms from the primary and/or secondary diagnoses, and relevant laboratory findings and diagnostic study. IV. You must be prepared to perform nursing procedures for which you have been checked off. These are recorded in your Skills Booklet. Skills will be performed in front of your clinical instructor. Under no circumstances are you to perform any skills, unless under the supervision of your clinical instructor/clinical assistant, until you are signed off as being proficient to perform without supervision or as indicated by your instructor. Even after being signed off as proficient, no skill is to be performed without notifying your instructor/assistant first. V. Each clinical day you are to perform a daily LPAT assessment. during the semester, your LPAT is to be observed by the instructor/assistant just as the other skills to be checked off as proficient. VI. Your clinical instructor is available to supervise procedures. VII. REGN 15- See Course Description, Student Learning Outcomes and Competencies, Clinical Evaluation Tool and Clinical Activities Portfolio for assignments. 100 Quick Chart Review Face sheet- age, sex, marital; status/significant other, religion, occupation, residence, next of kin and address, allergies, and insurance status. Physician's orders- admitting diagnosis, date of admission, current orders regarding: diet, activity, frequency of vital signs, daily weights, treatments, medications, diagnostic test ordered, IV therapy, and therapies ordered, i.e., -PT, OT, Respiratory. Nurse's notes- status during last 24 hours. Physician's progress notes- findings of last few days; status of problems. Graphic Sheet- Temperature, pulse, respiration, & blood pressure patterns, weight, I & 0 record, bowel pattern, PaOz patterns, pain level Medication Administration Record (MAR)- medications given, frequency of PRN medications and allergies. Physician's patient history and physical- current complaint, chronic problems, physical finding abnormalities, allergies, impressions, and plan for treatment. Surgery operative report- procedure done; organs removed; type of incision, drains or equipment in place, blood loss, and problems during surgery. Discharge summary- summary of the problems the patient had, how they were resolved, and plan of care after discharge. Pathology report- presence of malignancy or infection. Current diagnostic test- check for abnormal findings: CBC, UA, blood chemistries, x ray films, culture and sensitivity, EKG, and other tests. Nursing admission history and assessment- reason for hospitalization, smoking status, alcohol consumption status, last BM, special dietary requirements, use of aids or prostheses (hearing aid, glasses, artificial limb), medications taken regularly, identification of significant other, previous surgeries or hospitalizations, baseline vital signs, and physical abnormalities. Nursing care plan or problem list- patient's nursing diagnoses and interventions. Laboratory Data - Results of blood tests Radiology/X-Ray- Impressions and interpretations of radiological procedures Consultations, Etc. - Impressions and treatment plans of physicians invited to contribute to a special condition or problem. 101 Health Insurance Portability and Accountability Act of 1996 (HIPAA) Objective: Apply the principles of confidentiality in the provision of care. Overview: • First federal privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers • Effective April 14, 2003 • Developed by the Department of Health and Human Services (DHS) • Provide patients with access to their medical records and more control over how their personal health information is used and disclosed • Designed to encourage electronic transactions and also required new safeguards to protect the security and confidentiality of health information Patient Protections • Access to Medical Records. Able to see and obtain copies of their medical records and request corrections if they identify errors and mistakes. Access to be provided within 30 days of the request & may include charges for the cost of copying and sending the records. • Notice of Privacy Practices. Covered entities must provide notice to patients how they may use personal medical information & their rights under the new privacy regulation. This is usually handled with a disclosure statement signed by the patient. • Limits on Use of Personal Medical Information. Personal health information generally may not be used for purposes not related to health care & covered entities may use or share only the minimum amount of protected information needed for a particular purpose. A specific authorization is required before a covered entity could release medical information to a life insurer, a bank, a marketing firm or another outside business for purposes not related to health care. e Prohibition on Marketing. Covered entities must obtain an individual's specific authorization before disclosing their patient information for marketing. At the same time, the rule permits doctors and other covered entities to communicate freely with patients about treatment options and other health related information, including disease-management programs. • Stronger State Laws. The federal law provides a baseline for privacy & is superseded by stricter state laws when in place. When a state law requires a certain disclosure -such as reporting an infectious disease outbreak to the public health authorities- the federal privacy regulations would not preempt the state law. • Confidential communications - Patients can request that doctors, health plans and other covered entities take reasonable steps to ensure that communications with them are confidential. • Complaints. Complaints can be made to the covered provider or health plan or HHS' Office for Civil Rights (OCR}, which is charged with investigating complaints and enforcing the privacy regulation. Information about filing complaints should be included in each covered entity's notice of privacy practices. 102 Health Plans and Providers • Written Privacy Procedures. Must have written privacy procedures, including a description of staff that has access to protected information, how it will be used and when it may be disclosed. Covered entities generally must take steps to ensure that any business associates who have access to protected information agree to the same limitations on the use and disclosure of that information. • Employee Training and Privacy Officer. Covered entities must train employees in their privacy procedures & must designate an individual responsible for ensuring the procedures are followed. If violated the entity must take appropriate disciplinary action. • Public Responsibilities. Permitted disclosures include: emergency circumstances identification of the body of a deceased person, or the cause of death; public health needs; research that involves limited data or has been independently approved by an institutional Review Board or privacy board; oversight of the health care system; judicial and administrative proceedings; limited law enforcement activities; & activities related to national defense and security. The rule generally establishes safeguards & limits on these disclosures. • Equivalent Requirements for Government. Rules generally apply equally to private sector and public sector covered entities. Enforcement • Civil and Criminal Penalties. - Civil violations of the standards: Penalties up to $100 per violation, up to $25,000 per year, for each requirement or prohibition violated. Criminal penalties: Apply for certain actions such as knowingly obtaining protected health information in violation of the law. Up to $50,000 & one year in prison for certain offenses; up to $100,000 & up to five years in prison if the offenses are committed under "false pretenses" Up to $250,000 & up to 10 years in prison if the offenses are committed with the intent to sell, transfer or use protected health information for commercial advantage, personal gain or malicious harm. To learn more visit: http://www.hhs.gov/ocr/privacy/hipaa/understandinq!index.html Last revised: April14, 2003 U.S. Department of Health & Human Services- 200 Independence Ave., S.W. Washington, D.C., 20201 103 Confidentiality ../ Confidentiality is the duty to respect privileged information . ../ it is a basic ethical principle that ensures a client's privacy . ../ You are legally bound to keep client information confidential. ../ It is ground for dismissal from the program to not adhere to confidentiality . ../ Read your RN Handbook! ../ Avoid discussing the client's condition with anyone who is not involved in the case . ../ Do not share client's records with anyone outside of the hospital. ../ Do not tell information the client does not want told: even if you think others have the right to know. (e.g. clients with AIDS and family does not know but will be caring for client. You can't tell the client's family, just encourage the client to discuss it with them) . ../ Use client's initials ONLY on your paperwork . ../ No calling up other students in class and telling them about your patient. ../ Be careful walking in hallways, no talking about patients . ../ If you have a question about your duty/ethical responsibility with a client., please ask the instructors! 104 Geriatric Experiences- Resident Rights You have the right to exercise your rights, free of interference and coercion, discrimination, and reprisal. You have the right to be informed of all rules and regulations governing resident conduct, care and responsibilities during your stay in the facility. You have the right to manage your financial affairs. You have the right to choose your physician and to be informed about your care. You have the right to personal privacy and confidentiality. You have the right to voice grievances without discrimination or reprisal. You have the right to examine the most recent State Survey. You have the right to refuse to perform services for the facility. You have the right to send and promptly receive mail that is unopened. The facility must provide reasonable access to you by an entity or individual that provides health, social, legal or other services. You have the right to reasonable access tot the use of a telephone. You have the right to maintain and use your personal possessions. You have the right to share your room with your spouse. You may self-administer your medications, if this practice has been determined safe. You have the right to be notified of transfers and discharges. You have the right to be free from any physical and chemical restraints not required for your medical condition. You have the right to be fee from verbal, sexual, physical and mental abuse. You have the right to choose your activity schedules, and to interact with members of the community. You have the right to participate in social, religious, and community activities. 105 An Old Lady's Poem What do you see, nurses, what do you see? What are you thinking when you're looking at me? A crabby old woman, not very wise, Uncertain of habit, with faraway eyes? Who dribbles her food and makes no reply When you say in a loud voice, "I do wish you'd try!" Who seems not to notice the things that you do, And forever is losing a stocking or shoe .... Who, resisting or not, lets you do as you will, With bahting and feeding, the long day to fill .... Is that what you're thinking? Is that what you see? Then open your eyes, nurse; you're not looking at me. I'll tell you who I am as I sit here so still, As I do at your bidding, as I eat at your will. I'm a small child of ten ... with a father and mother, Brothers and sisters, who love one another. A young girl of sixteen, with wings on her feet, Dreaming that soon now a lover she'll meet! A bride soon at twenty- my heart gives a leap, Remembering the vows that I promised to keep. At twenty-five now, I have young of my own, Who need me to guide and a secure happy home. A woman of thirty, my young now grown fast, Bound to each other with ties that should last. At forty, my young sons have grown and are gone, But my man's beside me to see I don't mourn. At fifty once more, babies play around my knees, Again we know children, my loved one and me. Dark days are upon me, my husband is dead; I look at the future, I shudder with dread. For my young are all rearing young of their own, And I think of the years and the love that I've known. I'm now and old woman .... and nature is cruel; 'Tis just to make old age look like a fool. The body, the crumbles, grace and vigor depart, There is now a stone where I once had a heart. But inside this old carcass a young girl still dwells, And now and again my battered heart swells. I remember the joys, I remember the pain, And I'm loving and living life over again. I think of the years .... all too few, gone to fast, And accept the stark fact that nothing can last. So open your eyes, nurses, open and see. Not a crabby old woman; look closer.... see ME! Anonymous 106 Vital Signs Skill of the Week Objectives and Activities Identify when vital signs should be taken. Explain the principles and mechanisms of thermoregulation. Identify steps used to assess oral, rectal, axillary, and tympanic membrane temperature. Explain the physiology for normal regulation of TPR and BP (values from text). Identify steps used to assess TPR and BP. Identify normal vital sign values for an adult. • Accurately obtain and record vital sign measurements. Be able to show the following pulse points: carotid, apical, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, posterior tibial. Temperature Normal range to ______Assess activities prior to taking temperature (what actions may affect result) Pulse Characteristics Assess activities prior to taking pulse (what actions may affect result) Quality Rate Volume Rhythm Feel, it's rhythm Normal - bpm Force exerted by the ejected Regular or irregular and forcefulness Bardycardia< __bpm blood against the arterial wall Dysrhythmia/ Good-fair-bad Tachycardia> __bpm with each contraction arrhythmia: irregular heart Pulse deficit: apical> radial 0 Absent beat 1+ weak and thready 2+ normal 3+ bounding Respirations Normal range to--,----,--,-----,--- Assess activities prior to taking respirations (what actions may affect result) Blood Pressure Characteristics Assess activities prior to taking pulse (what actions may affect result) Normal: Systolic/ Diastolic ______ 107 Basic Pain Assessment • Acute Pain: Sudden onset and short duration (:: 6 months) • Chronic Pain -Long-term 2:_ 6 months) -Persistent, constant, or recurring pain that produces negative changes in life • Pain assessment Tool (0- 1 0) • Wong-Baker pain tool • Key questions to ask: Intensity, location, onset, duration, variation, quality No hurt Hurls Hurts a Hurls I-! uris Hurts littne bit liltle mora e\•en more wh~e lot wor·se • ®~. @ ® ®I ® @ II I I ,I I I I I Q; 1 2 3 4 5 G 7 8 9 10 No Pain Mild Nagging Miserable lntf~•n,se Worse Pain Pain Distressing Dreadlful Pain Ana;,oyfng Unoomrorlsble liftle!til@ tD Horrible Unbeal dD m.~sl Unal:ll!; IC· unal!la to do bliJ, dOBS r.10t .t~cli'i"ilh::~s ·.-vilh ac~lvi!F.as do rnvsl :an~· -i:LCL:h.'llios tl(!f::il~l$1,} lir'Ht11 ltC::ivity rt~:s-1 perioQ.c;: a~{:e."'-•illes- bf!1..!?.iiJSG olpaln be~,)US>:l or pntn ~.}1 P~'lhl 108 Procedure Checklist Assessing Body Temperature Check ( .Y ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics, and documentation. 1. Selects the appropriate site and thermometer type. 2. Inserts the thermometer in the sheath or uses a thermometer designated only for patient. 3. Inserts in chosen route/sit. a. Axillary: Dries axilla; places the thermometer tip in the middle of the axilla; Jowers patient's arm. b. Oral: Places the thermometer tip under the tongue in the posterior sublingual pocket (right or left of frenulum). Asks patient to keep lips closed. c. Rectal: Dons procedure gloves; lubricates thermometer; uses rectal thermometer; inserts 2.5-3.7 em (1-1.5 in.) in an adult; 2.5 em (0.9 in.) for a child, and 1.5 em (0.5 in.) for an infant. Holds rectal thermometer securely in place; does not leave patient unattended. d. Tympanic membrane: Positions patient's head to one side and straightens the ear canal. Unless manufacturer directs otherwise: 1) For an adult, pulls the pinna up and back. 2) For a child, pulls the pinna down and back. 4. Leaves an electronic thermometer until it beeps. 5. Reads the temperature. (For a glass thermometer, wipes with tissue before reading; reads at eye level). 6. Stores in recharging unit (electronic) or safe container (glass). 109 Procedure Steps Yes No Comments *Mercury-containing thermometers are not recommended. Use only glass thermometers filled with galinstan or alcohol. Recommendation: Pass ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 110 Procedure Checklist Assessing for an Apical-Radial Pulse Deficit Check ( .Y ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics, and documentation. 1. Cleanses the stethoscope before examining patient. 2. Obtains another nurse to assist. 1 3. Nurse 1 correctly locates and palpates the apical site (5 h intercostal space at the midclavicular line). 4. Places the watch so it is visible to both nurses. 5. Nurse 2 palpates the radial pulse; nurse 1 uses diaphragm of stethoscope to auscultate the apex. Correctly locates sites. 6. Nurse 2 calls "start" to begin counting and "stop" to end the count. 7. Counts for 60 seconds. 8. Notes rate, rhythm, and quality of radial pulse. 9. Identifies s, and S2 heart sounds. 10. Correctly obtains pulse deficit (apical rate minus radial rate). Variation: When performing this procedure without a second nurse to assist, holds the stethoscope in place with one hand while palpating the radial pulse with the hand wearing the watch. If it is not possible to count both rates, at least reports whether there are any differences between the apical and radial rates. Recommendation: Pass ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 111 Procedure Checklist Assessing Peripheral Pulses Check ( .Y ) Yes or No Procedure Steps Yes No Comments Note: You can use this checklist to evaluate on peripheral pulse, or to evaluate the student's ability to locate all the peripheral pulses Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics, and documentation. Circle the site used: Radial, brachial, carotid, dorsalis pedis, femoral, popliteal, posterior tibial, temporal 1. Selects, correctly locates, and palpates the site. 2. Uses fingers (not thumb) to palpate. 3. Counts for 30 seconds if regular; 60 seconds if irregular. 4. Notes rate, rhythm, and quality. 5. Compares bilaterally. 6. Carotid pulse: Palpates only on one side at a time. 7. Correctly locates the following sites: a. Radial b. Brachial c. Carotid d. Dorsalis pedis e. Femoral f. Posterior tibial g. Popliteal h. Femoral Recommendation: Pass. ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 112 Procedure Checklist Assessing Respirations Check ( ...f ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics, and documentation. 1. Flexes patient's arm and places patient's forearm across his chest, or otherwise counts unobtrusively. 2. Counts for 30 seconds if respirations are regular; 60 seconds if irregular. 3. Observes rate, rhythm, and depth. Recommendation: Pass, ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 113 Procedure Checklist Assessing the Apical Pulse Check ( .Y ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics, and documentation. 1. Assists patient to a supine or sitting position. 2. Cleans the stethoscope with a 70% alcohol or benzalkonium chloride wipe before using. 1 3. Selects, correctly locates, and palpates the apical site (5 h intercostal space at the midclavicular line). 4. Warms the stethoscope in the hands for 10 seconds. 5. Uses the diaphragm of stethoscope over the PM! (Point of Maximum Impulse). 6. Counts for 60 seconds. 7. Notes rate, rhythm, and quality. 8. Identifies S1 and S2 heart sounds. 9. Again, cleans the stethoscope with a 70% alcohol or benzalkonium chloride wipe before using. Recommendation: Pass ______Needs more practice ______ Student: ______Date: ______ Instructor:. ______Date: ______114 Procedure Checklist Assessing the Blood Pressure Check ( ) Yes or No Procedure Steps Yes No Comments Note: This checklist describes using the brachial artery in the upper arm; however, the checklist can also be used to assess lower arm, calf, and thigh blood pressures. Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics, and documentation. 1. Cleans the stethoscope before beginning the procedure. 2. Measures blood pressure after patient has been inactive for 5 minutes. 3. If possible, positions patient sitting, feet on flood, legs uncrossed; alternatively, lying down. 4. Exposes an arm (does not auscultate through clothing). 5. Supports patient's arm at the level of the heart. 6. Uses appropriately sized cuff. (The width of the bladder of a properly fitting cuff will cover approximately 2/3 of the length of the upper arm for an adult, and the entire upper arm for a child. Alternatively, the length of the bladder encircles 80% to 100% of the arm in adults). 7. Positions the cuff correctly; wraps snugly. 8. Palpates the brachial artery. a. Closes the sphygmomanometer valve. b. Inflates the cuff rapidly to about 80 mm Hg. c. While palpating the pulse, continues inflating 10 mm Hg increments until the pulse is no longer felt. d. Notes the pressure at which the pulse disappears. e. Continues inflating for 20-30 mm Hg more. 9. Alternate to Step 8. Palpates the brachial artery: a. Closes the sphygmomanometer valve. b. Inflates the cuff rapidly to about 80 mm Hg. c. While palpating the pulse, continues inflating in 10 mm Hg increments until the pulse is no longer felt. d. Notes the pressure at which the pulse disappears. e. Deflates the cuff rapidly. f. Waits 2 minutes, then places the stethoscope over the brachial artery and inflates the cuff to a pressure that is 20-30 mm Hg above the level previously palpated. 115 Procedure Steps Yes No Comments 10. Places the stethoscope over the brachial artery, ensuring that: a. The stethoscope is not touching anything (e.g., clothing). b. The diaphragm is not tucked under the edge of the BP cuff. 11. Releases pressure at 2-3 mm Hg/second. 12. Records at least systolic and diastolic readings (first and last sounds heart- e.g., 110/80). Records level of muffling, if possible. 13. If necessary to remeasure, waits at le~st 2 minutes. 14. Variation. If a mercury manometer m'ust be used, reads the scale at eye level. 15. Variation. If an automatic blood pressure device is used: a. Follows the same guidelines as for taking a manual blood pressure (e.g., cuff size and placement, patient position). b. Turns on the machine, making sure the cuff is deflated. c. Applies the cuff; presses the button to start the measurement. d. At the tone, reads the digital measurement. Recommendation: Pass, ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 116 Procedure Checklist Monitoring Pulse Oximetry (Arterial Oxygen Saturation) Check ( ...J ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics, and documentation. 1. Chooses a sensor appropriate for patient's age, size, and weight; and the desired location. 2. If patient is allergic to adhesive, uses a clip-on probe sensor. Uses a nasal sensor if patient's peripheral circulation is compromised. 3. Prepares the site by cleansing and drying. 4. If the finger is the desired monitoring location, removes nail polish or an acrylic nail, if present. 5. Removes the protective backing if using a disposable probe sensor that contains adhesive. 6. Attaches the probe sensor to the chosen site. Makes sure that the photodetector and light-emitting diodes on the probe sensor face each other. 7. If a clip-on probe sensor is used, warns patient that he may feel a pinching sensation. 8. Connects the sensor probe to the oximeter and turns it on. Makes sure the oximeter is plugged into an electrical socket. 9. Checks the pulse rate displayed on the oximeter to see if it correlates with patient's radial pulse. 10. Reads the Sao2 measurement on the digital display when it reaches a constant value, usually in 10-30 seconds. 11. Sets and turns on the alarm limits for Sao2 and pulse rate, according to the manufacturer's instructions, patient condition, and agency policy, if continuous monitoring is necessary. 12. Obtains readings as ordered or indicated by patient's respiratory status. 13. Rotates the probe site every 4 hours for an adhesive probe sensor and every 2 hours for a clip-on probe sensor, if continuous monitoring is indicated. 14. Removes the probe sensor and turns off the oximeter when monitoring is no longer necessary. 117 Recommendation: Pass______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 118 APPENDIX M- Medical Abbreviations and Symbols List Welcome to the new abbreviation and symbol list. This is not a complete listing of medical abbreviations or symbols, but contains commonly found abbreviations used in Adult Care Home and In Home Service settings. Abbreviation Meaning a before ac before meals abd abdomen AD Alzheimer's disease; right ear ADL activities of daily living ad lib as desired AKA above the knee amputation amb ambulation (walk) ama, AMA against medical advice, American Medical Assoc. AMI acute myocardial infarction ANS autonomic nervous system appt appointment ARDS adult respiratory distress AROM active range of motion AS left ear; aortic stenosis AVR aortic valve replacement AV atrioventricular (heart) ASAP as soon as possible ASHD arterisosclerotic heart disease BID, bid twice in the day BKA below knee amputation BM bowel movement BP blood pressure BPH benign prostatic hypertrophy (enlarged prostate gland) BR or br bath room BSC bed side commode, a "portable potty chair'' BUN blood urea nitrogen (a lab test) Bx or BX biopsy c- with c/o complaints of C1, C2 refers to cervical vertebra #1, #2, a location in the spine Ca,CA cancer caps capsule with medication in it CAD coronary artery disease (heart disease) CAT or CT scan computerized axial tomography (CAT scan of the body) cath catheter (a tube used to drain out body fluid) NC DSS Adult and Family Services Section, November 1, 1998 119 Medical Abbreviations and Symbols, page 2 CABG coronary arterial bypass graft CBC complete blood count ( a blood test) cc chief complaint; cardiac catheterization ccu coronary care unit CHD coronary heart disease CHF congestive heart failure CNS central nervous system cont. continued COPD chronic obstructive pulmonary disease C02 carbon dioxide CPR cardiopulmonary resuscitation CXR chest xray CRF chronic renal failure (kidney failure) CVA cerebral vascular accident CVD cardiovascular disease cvs cardiovascular system cysto cystoscopy /d per day DC or D/C discharge de discontinue decub decubitus ulcer (pressure sore, bedsore) DJD degenerative joint disease (osteoarthritis) OM diabetes mellitus (diabetes) DOA date of admission; dead on arrival DOB date of birth Ox diagnosis drsg dressing DSD dry sterile dressing DT, DTs delirium tremens ("the shakes" from alcohol withdrawal) ECG,EKG electrocardiogram EEG electroencephalogram (measurement of electric brain activity) e.g. example ENT ears, nose, throat ERT estrogen replacement therapy est, EST estimate; electroshock therapy ETOH ethanol (alcohol) FBS fasting blood sugar (a lab test) F/U FU follow up FUO fever of unknown origin Fx fracture G tube gastric tube (a tube in the stomach) GB gall bladder GBS gall bladder series (a type of xray of the gut) NC DSS Adult and Family Services Section, November 1, 1998 120 Medical Abbreviations and Symbols, page 3 GC gonorrhea GERO gastroesophageal reflux disease (a severe recurrent heartburn disorder) GU genitourinary gtts drops gyn gynecology hgb hct hemoglobin, hematocrit, (both are blood cell measurements) HHA home health agency; or home health aide H20 water HS, hs hour of sleep, or at bedtime ht height Hx hx history 1&0 intake and output ( amount of fluid taken in and urine output) ICF intermediate care facility ICU intensive care unit 10 incision and drainage (when a scalpel is used to cut & drain a boil) lOOM insulin dependent diabetes mellitus IM intramuscular inj injection IV intravenous IVP intravenous pyelogram ( a type of xray of the kidneys and bladder) L If! It left L1, L2, L3 refers to the lumbar section of the spine lab laboratory liq liquid LLQ left lower quadrant LP lumbar puncture (spinal tap) LPN licensed practical nurse LRQ lower right quadrant LUQ left upper quadrant LV left ventricle max maximum meds medications Ml myocardial infarction (heart attack) mod moderate MRI magnetic resonance imaging MS mitral stenosis; multiple sclerosis; musculoskeletal MVR mitral valve replacement N/C no complaints NG, NGT nasogastric (tube) NC DSS Adult and Family Services Section, November 1, 1998 121 Medical Abbreviations and Symbols, page 4 NIDDM non-insulin dependent diabetes mellitus noc night norm normal NPO nothing by mouth NSAID nonsteroidal anti-inflammatory drug nsg nursing OA osteoarthritis OBS organic brain syndrome ace occasional OD right eye; overdose OOB out of bed OS left eye ou both eyes orth ortho orthopedic OS bone; opening; mouth ov office visit 02 oxygen p after p pulse PA physician assistant Pap pap smear ( a lab test) path pathology pc, p.c. after meals PDR physician's desk reference (a drug handbook) PE pe physical exam prn, p.r.n. as needed or required PROM passive range of motion PO pa my mouth pt patient PVC premature ventricular contraction PVD peripheral vascular disease ph pH hydrogen ion concentration ( a measure of the acidity of a substance) q every qam every am qd every day qod every other day qh every hour q2h,q3h,q4h every 2 hours, every 3 hours, every 4 hours qhs every night (hour of sleep) qid four times a day quad quadriplegic ( arms and legs paralyzed) R, rt right NC DSS Adult and Family Services Section, November 1, 1998 122 Medical Abbreviations and Symbols, page 5 RA right atrium re: about or regarding rbc, RBC red blood cell reg regular resp respiration or breaths RLQ right lower quadrant RN registered nurse R/0, r/o rule out ROM range of motion RUQ right upper quadrant RV right ventricle Rx, RX treatment s- without SA sinoatrial node sl sublingual meaning under the tongue sm small SOB short of breath S/P, s/p status post (status post an "event", s/p Ml, s/p CVA, s/p Gl bleed) spec specimen spec grav, sp gr specific gravity (urine test) s & s, s/s signs and symptoms staph staphylococcus stat immediately STD sexually transmitted disease strep streptococcus subq, subc subcutaneous symp, Sx symptom T temperature T1, T2, T3 refers to the thoracic section of the spine tab tablet, a tablet of medication, a round pill TB tuberculosis THR total hip replacement TIA transient ischemic attack tid three times a day TKR total knee replacement T/0, tlo telephone order TPR temperature, pulse, respiration (the measurement of these 3 things) tsp teaspoon measurement TUR, TURP transurethral resection (prostate gland surgery in men) Tx treatment U/A, u/a urine analysis NC DSS Adult and Family Services Section, November 1, 1998 123 Medical Abbreviations and Symbols, page 6 URI upper respiratory infection UTI urinary tract infection VD venereal disease VO, v/o verbal order vs, VS, v/s vital signs (temperature, pulse and respiration measurements) WBC, wbc white blood cell W/C wheel chair WNL within normal limits w/o without wt weight w/u work up X times y/o years old yr year Commonly Used Symbols increase "' decrease "' approximately # number @ at 0 degree > greater than < Jess than + positive negative +, & and 0 nothing, not, none = equal to not equal to cf male Q* female T one of something TI,m 2, 3 of something (dss.abrvlist/98) NC DSS Adult and Family Services Section, November 1, 1998 124 Guidelines for Documentation Factual 1. Objective. direct observations; See, Feel, Hear, Smell 2. Subjective information needs factual support. "Quotes" if the person says it. Accurate 3. Specific measurements: Use only approved abbreviations; spell out if confusing term. 4. Only correct spelling and legible handwriting. Chart only for yourself. The chart is a legal document. 5. Ink. No erasing, correction fluid or skipping lines. Correct errors promptly. One line through. Example: 1500- c/o RLQ abd pain x30 min states 6 on 1-10 scale, medicated with Demerol 50 mg IM------Lyn Nurse, SN 6. Avoid phrases like "Had a nice night". 7. Record clarification of orders. Never make critical remarks about staff in the chart. Concise The whole focus is the client, so there's no need to repeatedly say "the client" or "the patient" unless those words are necessary to clarify. Leave out the, §han, if the words aren't needed for clarification. Begin each statement with a capital letter and end with a period. Current Chart as soon as reasonable after the event. Charting ahead of time is not acceptable. Time each entry. Military time must be understood. Confidential Notes not open to public view. Illegal to share confidential info. *************************************** You will need to review different types of charting. At the clinical facilities we use for first semester, you'll find many charting methods/forms. 125 Procedure Checklist Hand Washing Check ( -.J ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics, and documentation. 1. Pushes up the sleeves; removes jewelry and watch. 2. Adjusts water temperature to warm. 3. Wets hands and wrists under running water, keeping hands lower than wrists and forearms. 4. Avoids splashing water onto clothing. 5. Avoids touching inside of the sink. 6. Applies 3-5 ml liquid soap. 7. Rubs soap over all surfaces of hands. 8. Rubs hands vigorously together for at least 15 seconds. 9. Lathers all surfaces of the hands and fingers. 10. Cleans under fingernails, if nails are dirty. 11. Rinses thoroughly, keeping hands lower than forearms. 12. Dries hands thoroughly: moves from fingers up forearms; blots with paper towel. 13. Turns off faucet with paper towel. 14. Applies non-petroleum-based hand lotion or skin protectant. Using alcohol-Based Handrub: 1. If hands are soiled, washes them with soap and water. 2. Removes jewelry, bares arms, and so on, as with the soap- and-water procedure. 3. Applies a sufficient quantity of antiseptic solution to cover the hands and wrists. 4. Rubs solution on all surfaces of fingers and hands. 5. Continues rubbing until hands are dry, or as recommend by the manufacturer or agency policy. 126 Procedure Steps Yes No Comments Recommendation: Pass, ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 127 Hand Hygiene Skill of the Week Objective and Activities • Successfully perform proper procedures for hand washing . Rational: Procedure • Prevent and control transmissions of • Inspect for breaks or cuts infections • Remove rings, watch, clothing from • Instant alcohol hand antiseptic wrists before and after care • Turn on water; avoid splashing Hand washing with soap and water • • Wet hands and forearms lower then -When hands visibly soiled elbows -When performing surgical scrub • Wash with soap and water -Friction is important Other option: -15 sec. between pts. • Use alcohol-based waterless antiseptic -One minute: when hands not soiled -Before a procedure 0 Apply ample amount to palm -When arriving to work • Rub hands together -When leaving the floor • Cover all surfaces • Clean nails - no artificial nails • Rub hands together until alcohol is dry • Dry from fingers to elbows • Use lotion as needed • Turn off faucet with dry paper towel • Apply lotion as needed 128 Intravenous Infusions Skill of the Week Objective and Activities • Demonstrate safe discontinue of an IV in lab or clinical setting. • Demonstrate safe monitoring of an IV site in lab or clinical setting. Complication: • Infiltration (IV fluids in SubQ space ... swelling, pallor, pain) v' Nursing Action: Discontinue IV, elevate affected extremity, restart IV in alternate site if fluids still needed. • Phlebitis (inflammation of vein ... pain, heat over vein, redness) v' Nursing Action: Discontinue IV, apply moist, warm compress to inflamed area for comfort, restart IV if fluids are needed. • Fluid overload (too rapid an administration) v' Nursing Action: Reduce IV flow rate, notify MD • Bleeding (around venipuncture site, usually an oozing) v' Nursing Action: Monitor IV closely, if catheter is in the vein, apply dry dressing. Will eventually have to be restarted if continued therapy needed. Monitoring • Assess the site every hour & document findings. • Note amount in bag as you come on shift and do initial assessment. • Note amount in bag as you leave shift. The difference is the amount that the patient received. Caution: new bags added, fluid wasted, piggyback or blood or medications added. • IV bag (main IV solution ordered by the physician, such as D5W, 0.9 NaG!, or Lactated Ringers) • Piggyback bag (smaller IV bag, usually 50-100 ml, which contains some medication that is administered intermittently, such as an antibiotic, and is delivered over 30-60 minutes) • IV tubing (goes from the IV bag to the patient, be sure to check the drip rate on the box) • Extension Tubing (makes the IV tubing longer, from main IV tubing to the patient) • Drip chamber (the bubble-like chamber located near the bag to assess flow) • Drip regulator (this can either be a roller clamp, or some other mechanical means of controlling the rate of flow of the IV solution. Check the doctor's order for flow rates) Removal of IV Documentation • Reasons • Identify which I.V. site -Complications • Describe the I.V. site -Infiltration • If cannula is intact or not -Phlebitis: mechanical or • Any complications (hematoma, chemical bleeding, skin tear) -Bleeding/bruising • Client tolerance and comfort -Cellulitis -Extravasation -IV treatment completed Charting that you have discontinued an IV site can be simple. You need to watch your: • Spelling (look it up if you are unsure • Handwriting (neat, legible, in black ink) • Terminology (use appropriate abbreviations, etc.) • Completeness (contains time, page is dated, all the issues below are addressed, signed with your first initial, last name, title) • Accuracy (correct chart) 129 First state which IV site is being addressed by its specific location & why the IV was DC'd (complications or completed therapy), then describe the site using terms like reddened, swollen, painful, warm to the touch, and bleeding. Next document the condition of the cannula (intact or not). Include any complications such as excessive bleeding when the IV was removed & what was done (e.g., "pressure held to area x5 minutes with no further bleeding"). Finally address comfort & safety issues. Document how the patient tolerated the procedure, and that you left them in a safe environment (bed down, side rails up x 2, call bell in reach). An example of the above would be: 1615 IV site L antecubital reddened, leaking clear fluid, swollen, and painful. IV removed, cannula intact patient to/ procedure well. Bed in low position, side rails up x2, call bell in reach. J. Doe, RN notified at 1620, states she will restart IV ...... H. Smith, SN Student Name: ______Date: ______ Activity Date Instructor Administering IV Fluid Therapy- Mosby CO/Advanced (all parts) Skill Check off: Discontinuing an IV s Comments 1. Determine appropriateness, verify orders, gather equipment, wash hands, ID client, provide privacy, & explain procedure. 2. Prepare supplies, apply gloves. Stop IV solution if present. 3. Loosen tape & occlusive dressing, pull toward site. 4. Place 2 x 2 or other dressing over IV site and pull IV catheter out even with the skin. Apply pressure over site. Examine catheter for intactness. 5. Remove gloves & dispose of IV equipment. Perform hand hygiene. Document actions/findings. Check off by: ___-;:c--,----,------Check off by: ___-::--,----,------student Evaluator Date: ______Date: ______ 130 Restraints Skill of the Week Objectives and Activities List guidelines and rationales for the use of restraints Be able to state your legal obligations when applying restraints to clients Successfully and safely apply wrist/ankle, and jacket/vest restraints Classifications • Chemical: Use of medications to control patient behavior • Physical: Decreases patient movement through the application of a device Restraint Types 1. Jacket: Vest with straps that cross in front or in the back of the client and are ties to the bed frame or chair 2. Belt: Straps or belts applied across the client to secure to the stretcher, bed or wheelchair. 3. Mitten or hand: Enclosed cloth material applied over the clients hand to prevent injury from scratching. 4. Elbow: A combination of fabric and plastic or wooden tongue blades that immobilized the elbow to prevent flexion. 5. Limb or extremity wrist: Cloth devices that immobilize one or all limbs by securely tying the restraint to the bed frame or chair. 6. Mummy: A blanket or sheet that is folded around the client to limit movement. The Controversy • Vest restraints banned in Nursing Homes. • Estimated 50 - 100 deaths/yr from restraints. • Use contributes to increase in infection, anger, nosocomial infections, pressure ulcers. Guideline = Physician's order MUST be obtained and renewed every 24 hours w/justified documentation • Nurses: -MUST be knowledgeable of and follow hospital procedure accurately -May be held liable if there is evidence that standards of practice ignored/violated -Documentation MUST include client's precipitation behavior for use of restraint -Use quick release knots, insert 2 fingers under restraint to keep from being too tight Safety • Release q2 hrs for 30 minutes and check CMS and provide ROM • Assist client to the bathroom q 2 hours • Stay with client or provide other safety measures while out of restraints 131 Procedure Checklist Using Restraints Check ( ...J ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics, and documentation. 1. Follows agency policy, state laws, and Medicare standards for using restraints, as applicable. 2. Tries alternative interventions first (e.g., bed alarm, patient sitter). 3. Uses least invasive method of restraint that is likely to be effective. 4. Determines that one of the following applies. Patient: a. Is a danger to self or others. b. Must be immobilized temporarily to perform a procedure. 5. Obtains a medical order before restraining, except in an emergency. 6. Notifies the family. 7. Obtains written consent. Applying Restraints: 8. Obtains the properly sized retrain!. 9. Pads bony prominences before applying the restraint. 10. Secures straps in a way that allows for quick release. 11. Does not tie restraints to the bed rail; ties to the bed frame or chair frame. 12. Adjusts restraint to maintain good body alignment, comfort, and safety. 13. Assesses that restraints are snug enough to prevent them from slipping off, but not tight enough to impair blood circulation or skin integrity (e.g., should be able to slide two fingers under a wrist or ankle restraint). Caring for a Patient in Restraints: 14. Checks restraints every 30 minutes. 15. Checks that a prescriber reassess and reorders restraints every 24 hours. 132 Procedure Steps Yes No Comments 16. Releases restraints and assesses every 2 hours (more often for behavioral restraints); provides skin care, range of motion, ambulation, and toileting. 17. At least every 2 hours, assesses circulation, skin integrity, and need for continuing restraint. Recommendation: Pass ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 133 Universal Precautions/Protective Equipment Universal Precautions/Protective Equipment . Skill of the Week Objectives & Activities • Compare body substance isolation with universal blood and body fluid precautions • Successfully perform putting on cove gown (non-sterile), gloves & mask/shield for protection Wash hands (plain soap) • After touching blood , body fluids, secretions, excretions & contaminated items • Wash immediately after gloves removed & before & after client contact Wear gloves • When touching blood, body fluids, secretions, excretions & contaminated items • Clean gloves just before touching mucous membranes & non-intact skin • Change between tasks & procedures on same client when likelihood of touching contaminated surfaces • Remove promptly upon completion of use, before touching non-contaminated items, environmental surfaces, before going to another client, wash hand immediately Wear mask & eye protection or face shield • whenever likelihood of activities that generate a splash or spay of blood, body fluids, secretions or excretions Client care equipment • Use appropriate protection against contaminating yourself while handling soiled equipment • ensure all reusable equipment is disinfected before reuse Environmental control • Follow established facility policies for routine care & cleaning of clients rooms Linen • Handle all used linen in a manner that avoids transfer of microorganisms to self & others Occupational Health & Blood Borne Pathogens • Prevent injuries when using, cleaning or disposing of needles scalpel or other sharp instruments • Never recap needles • Never bend or manipulate needles, blades, scalpels or other sharp object • Use resuscitation devices as an alternative to mouth-to-mouth resuscitation Client Placement • Use a private room for clients contaminated or for those who are unable to assist in maintaining appropriate hygiene or environmental control • consult the infection control nurse for assistance 134 Procedure Checklist Donning Personal Protective Equipment (PPE) Check ( ...J ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics, and documentation. 1. Assesses the need for personal protective equipment. Gloves: When the nurse may be exposed to potentially infectious secretions or materials. Gowns: When the nurse's uniform may become exposed to potentially infectious secretions. Face shield or eye goggles: When splashing may occur and potentially contaminate the nurse's eyes. N-95 respirator. When caring for patients infected with airborne microorganism. Hair cover. When there is potential for splashes or sprays of body fluids. Shoe cover. When there is potential for contaminating shoes with body fluids. 2. Determines availability of appropriate PPE. 3. Dons gown first. a. Picks up the gown by the shoulders; allows to fall open without touching any contaminated surface. b. Slips arms into the sleeves; fastens ties at the neck. c. If the gown does not completely cover clothing, wears two gowns. Places the first gown on with the opening in the front and then places the second gown over the first with the opening in the back. 4. Dons a face mask. Identifies the top edge of the mask by locating the thin metal strip that goes over the bridge of the nose. a. Picks up the mask with the top ties or ear loops. b. Places the metal strip over the bridge of the nose and ties upper ties or slips loops around the ears. c. Places the lower edge of the mask below the chin and ties lower ties. d. Presses the metal strip so it conforms to the bridge of the nose. 5. Dons the face shield by placing the shield over the eyes, adjusting metal strip over bridge of nose, and tucking the lower edge below the chin. Secures straps behind head. 6. If using safety glasses or goggles, dons them by setting them over the top edge of the face mask. 135 Procedure Steps Yes No Comments 7. Dons hair cover (as indicated). 8. Dons shoe covers (as indicated). 9. Dons gloves. Selects the appropriate size. 10. If wearing a gown, makes sure that the glove cuff extends over the cuff of the gown. 11. If there is not complete coverage, tapes the glove cuff to the gown. . Recommendation: Pass. ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 136 Procedure Checklist Removing Personal Protective Equipment (PPE) Check ( -.J ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics, and documentation. Removes PPE in the following order: 1. If wearing a gown that is tied in front, unties waist ties. 2. Removes gloves. (If gown is tied in back, removes gloves first). a. Removes one glove by grasping the cuff of the glove and pulling down so the glove turns inside out. Holds the glove removed in the remaining gloved hand. b. Slips the fingers of the ungloved hand inside the cuff of the other glove; pulls glove off inside out, turning it over to enclose the first glove. Does not touch self with the contaminated surface of either glove. c. Holds the contaminated gloves away from the body. d. Disposes of gloves in a designated waste receptacle. 3. Removes gown. a. Releases neck ties of gown, allowing the gown to fall forward. b. Places the metal strip over the bridge of the nose and ties upper ties or slips loops around the ears. c. Reaches inside to pull off the cuff and remove the arm from the sleeve, one arm at a time. d. Holding the gown away from body, folds inside-out and discards. Does not contaminate clothing with the dirty gown. (Note: If wearing two gowns, second gown is removed now). 4. Removes goggles before the mask. Grasps by ear pieces. 5. Removes the mask or face shield by untying lower ties first; unties upper ties next; disposes in designated waste receptacle. Does not touch the front of the mask. 6. Removes hair covering. Slips fingers under the edge of the hair cover; does not touch the outside of it. Disposes of hair cover properly. 7. Washes hands before leaving the room. 8. Closes the door on leaving. -~.., Recommendation: Pass, ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 138 Transmission Based Isolation Precautions Airborne Droplet Contact Neutropenic Diseases • TB (known or • Meningococcal • MRSA, VRE, other • Immunosuppressed suspected) Disease multi-drug resistant • Absolute neutrophil • Measles (Rubeola) • Pertussis organisms count< 500 • Chickenpox • Acute influenza • RSV (respiratory (Varicella) • Mumps syncytial virus) • Disseminated • Rubella • Pediculosis, scabies Herpes Zoster • Strep pharyngitis (status pre 24 hr. (status pre 24 hr tx) effective tx) • Major wounds (unable to contain drainage with dressing •Infectious diarrhea when difficult to contain (ex: C difficile) Private Room Yes Yes Yes Yes Flowers - ask MD Negative Yes No No No Pressure Closed Door Yes No No No Hand washing Yes, upon entering & Yes, upon entering & Yes, upon entering & Yes, upon entering & exit & when likely exit & when likely imperative on exit exit contaminated contaminated Gloves Yes when contact with Yes when contact with Yes when entering the Yes when contact with body fluids likely body fluids likely room. Avoid touching body fluids likely surfaces when gloves are contaminated. Remove in the room & wash hands, do not touch surfaces with clean hands. Mask Yes, fit tested. Yes, surgical mask No, unless splashing No, unless ordered by when within 3 feet of is likely MD client Gown Yes, when clothing Yes, when clothing Yes, with direct care Yes, when clothing may become soiled may become soiled or contact with may become soiled with body fluids with body fluids surfaces or equipment with body fluids Equipment Disinfect when soiled Disinfect when soiled Dedicate BP cuff, Disinfect when soiled with body fluids with body fluids stethoscope, glucose with body fluids monitor, thermometer & wheelchair or walker to client room. Disinfect when removed from room. Transportation Client wears surgical Client wears surgical Client with clean gown Consult with MD. mask, staff wears mask & linen. Drainage Client to mask when respirator mask must be contained. around others. Client may ambulate in hall. D/C MD, Infection control MD, Infection control MD, infection control MD Precautions nurse. County Public nurse nurse Health Dept aware of discharges Visitors Respirator masks, Isolation instructions, Isolation instructions, Evaluate for isolation instructions, surgical mask if within gloves if contact with communicable illness. hand washing 3 feet of client, hand secretions likely, hand Isolation instructions, washino washino hand washino 139 Procedure Checklist Making an Occupied Bed Check ( .Y ) Yes or No Procedure Steps Yes No Comments Note: This checklist is designed to evaluate making an occupied bed separately from giving a bed bath. If linen change is done at the time as the bed bath, some of these steps will vary. Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics, and documentation. 1. Prepares the environment as needed: a. Moves furniture to allow access to the bed. b. Positions the linen hamper for easy access. 2. Dons protective gloves and other gear if necessary. 3. Positions the bed flat if possible, and raises to the appropriate working height. Lowers the side rail nearest the nurse. 4. Disconnects the call device and removes patient's personal items from the bed. 5. Checks that no tubes are entangled in the bed linens. 6. Leaves the side rail down only on the side of the bed where the nurse is standing. Does not walk to the other side with the rail still down. 7. Removes blanket and/or bedspread; if clean, folds and places on a clean area. Does not place clean linen on another patient's bed or furniture. 8. Covers patient with a bath blanket, if available, or leaves the top sheet over patient. 9. Positions patient: a. Slides patient to the far side of the bed; places in a side- lying position facinQ the side rail. b. Places a pillow under patient's head; if needed, places a pillow between patient and the side rail. 10. Rolls or tightly fan-folds the soiled linens toward patient's back; tucks the roll slightly under patient. 11. Covers any moist areas of the soiled linen with a waterproof pad. 12. Removes soiled gloves; performs hand hygiene; and dons clean procedure gloves. 13. Places a clean bottom sheet and drawsheet on near side of the mattress, with the center vertical fold at the center of the bed. 140 Procedure Steps Yes No Comments 14. Fanfolds the half of the clean linen that is to be used on the far side, folding it as close to patient as possible and tucking it under the dirty linen. 15. Tucks the lower edges of clean linen under the mattress. Smoothes out all wrinkles. 16. Explains to patient that he will be rolling over a "lump". 17. Rolls patient over dirty linen and gently pulls patient toward the nurse so patient rolls onto the clean linen. 18. Raises the side rail on the clean side of the bed. 19. Moves to opposite side of bed; lowers the bed rail. 20. Pulls soiled linen away from patient. Removes from the bed and places in a laundry bag or hamper without contaminating the uniform. 21. Does not put soiled linen on the floor or other surfaces. 22. Moves pillows to the clean side of the bed; positions patient side-lying near the bed rail on the clean side. 23. Removes soiled gloves, performs hand hygiene, and dons clean procedure gloves. 24. Pulls clean linens through to the unmade side of the bed, and tucks them in. 25. Pulls linens taut, starting with the middle section. 26. Assists patient to a supine position close to the center of the mattress. 27. Places the top sheet and bedspread along one side of the mattress; removes the bath blanket. 28. Tucks sheet and blanket in at the same time, then moves to the opposite side of the bed. 29. After making both sides of the bed, at the head of the bed, folds sheet down over the bedspread. 30. At the foot of the bed, makes a small toe pleat in the top sheet and bedspread; then tucks in the bottom of the sheet and bedspread at the same time. 31. Miters corners neatly. 32. Changes pillowcases: Turns inside out; grasps the middle of the closed end of the pillowcase; reaches through the pillowcase and grasps the end of the pillow; pulls the pillow back through the pillowcase. Does not hold the pillow under an arm or the chin. 33. Returns the bed to a low position, raises side rails, and attaches the call light within patient's reach .. 141 Procedure Steps Yes No Comments 34. Positions the bedside table and overbed table within patient's reach. Recommendation: Pass. ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 142 Procedure Checklist Making an Unoccupied Bed Check ( ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics, and documentation. 1. Assists patient to the chair; provides a robe/blanket if needed. 2. Prepares the environment: a. Positions the bed flat, raises to working height, and lowers side rails b. Moves furniture as needed. c. Places the linen hamper for convenient access. 3. Dons gloves and protective gear if necessary. 4. Loosens all bedding. 5. Folds and places clean bedspread and/or blanket on clean area. Does not place clean linen on another patient's bed or furniture. 6. Removes all sheets and pillowcases; places in a laundry bag or hamper without contaminating uniform. a. Does not shake or "fan" linens. b. Does not place linens on the floor. c. Removes and replaces linens on one side of the bed at a time, to save steps. 7. For a flat bottom sheet, allows at least 10 inches to hang over at tope and side for tuck-in. 8. Smoothes wrinkles from the bottom sheet. 9. If there is a draw sheet, tucks it and draws it tight. 10. Replaces the waterproof pad if one is being used. 11. Places the top sheet and bedspread along one side of the mattress; unfolds. 12. Makes a small pleat in the top sheet and bedspread, at the foot of the bed. 13. Tucks the top sheet and bedspread in at the same time, using a mitered corner. Then moves to the opposite side of the bed. 143 Procedure Steps Yes No Comments 14. After making both sides of the bed, at the head of the bed, folds the sheet down over the bedspread. 15. Fanfolds the top sheet and bedspread back to the foot of the bed. 16. Changes pillowcases: a. Turns the pillowcase wrong side out. b. Grasps the middle of the closed end of the pillowcase. c. Reaches through the pillowcase and grasps the end of the pillow. d. Pulls the pillow back through the pillowcase. e. Does not hold the pillow under an arm or the chin. 17. Assists patient back to bed. 18. Places the call signal within reach; puts the bed in a low position. 19. Places the bedside table and overbed table so they are accessible to patient. Recommendation: Pass. ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 144 Procedure Checklist Providing Oral Care for an Unconscious Patient Check ( .Y ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics, and documentation. 1. Determines whether patient has dentures or partial plate; access the gag reflex. 2. Positions patient in a side-lying position with head turned to the side, if possible, and with head of bed down (slightly dependent, if possible). 3. Dons procedure gloves, eye goggles, and any other protective gear needed. 4. Places waterproof pad and then towel under patient's cheek and chin. 5. Sets up suction: Attaches tubing and tonsil-tip suction, checks suction. 6. Brushes patient's teeth: a. Uses a padded tongue blade or bit-block to hold the mouth open. b. Places an emesis basin under patient's cheek. c. Moistens a toothbrush and applies a small amount of toothpaste. d. Brushes teeth, holding bristles at a 45° angle to the gum line. e. Uses short, circular motions. f. Gently brushes the inner and outer surfaces of the teeth, including the gum line. g. Brushes the biting surface of the back teeth by holding the toothbrush perpendicular to the teeth and brushing back and forth. h. Brushes patient's tongue. i. Performs oral suctioning when fluid accumulates in the mouth. 7. Draws about 10 ml of water or mouthwash (e.g., dilute hydrogen peroxide) into a syringe; ejects it gently into the side of the mouth. Allows the fluid to drain out into the basin; or suctions as needed. 145 Procedure Steps Yes No Comments B. Cleans the tissues in the oral cavity according to agency policy. a. Uses foam swabs or moistened gauze square wrapped around a tongue blade. b. Uses a clean swab for each area of the mouth: cheeks, tongue, roof of the mouth, and so forth. 9. Removes the basin, dries face and mouth, applies water- soluble lip moisturizer. 10. Removes the waterproof pad and towel. 11. Turns off suction equipment. 12. Discards gloves and used supplies. 13. Repositions patient as needed. 14. Cleans and stores reusable oral hygiene tools in clean containers, separate from other articles of personal hygiene. Recommendation: Pass. ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 146 Procedure Checklist Providing Denture Care Check ( -.J ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics, and documentation. 1. Dons procedure gloves. 2. Removes the upper denture before the lower denture. 3. To remove the upper denture, with a gauze pad, grasps the denture with a thumb and forefinger and moves gently up and down. Tilts the denture slightly to one side to remove it without stretching the lips. 4. To remove lower denture, uses thumbs to gently push up on denture at gum line to release from lower jaw. Grasps the denture with thumb and forefinger and tilts to remove the patient's mouth. 5. Places each denture in a denture cup after removing. 6. Places a towel or basin of water in the sink to prevent damage to dentures. 7. Cleanses the dentures under cool running water. 8. Applies a small amount of toothpaste to stiff-bristled toothbrush; brushes all surfaces of each denture; rinses thoroughly with cool water. *Obtain hospital policy Alternatively, soaks stained dentures in a commercial cleaner, following the manufacturer's instructions. 9. Inspects dentures for rough, worn, or sharp edges before replacing. 10. Inspects the mouth under the dentures for redness, irritation, lesions, or infection before replacing dentures. 11. Applies denture adhesive as needed or as desired by patient. 12. Replaces the upper denture before the lower denture. 13. Moistens the upper denture, if dry; inserts at a slight tilt, and presses it up against the roof of the mouth. 14. Moistens the bottom denture, if dry; inserts the denture, rotating as it is placed in patient's mouth. 15. If patient does not wish to wear the dentures, covers them with water in a denture container with a lid. Labels the container with patient's name and agency identifying number. 147 Procedure Steps Yes No Comments 16. Offers mouthwash. Recommendation: Pass. ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 148 Oral & Denture Care Oral & Denture Care Skill ofthe Week Objectives & Activities • Discuss measures to provide oral hygiene. • Demonstrate correct denture care in lab setting. • Assist with/provide oral hygiene to classmate. • Be able to demonstrate mouth care for an unconscious client. • Correctly setup and demonstrate use of a Yankauer catheter in suctioning oral secretions. • Practice feeding another student. Non-Sterile Suctioning: • Remember not to suction more than 15 seconds, as no oxygen gets to the lungs during suctioning. • Use oropharyngeal/nasopharyngeal suctioning when pt. can cough but not able to clear secretions. Have patient cough first. 149 Bathing & Pericare Skill of the Week Objectives.& Activities • Successfully perform proper technique in performing a complete bed bath (come prepared for lab with swimsuit, shorts, or other attire that will allow students to bathe each other--also bring towel, wash cloth, and toothbrush) • Describe factors that influence personal hygienic practices • Accurately document ADL's and basic care on form provided in lab and/or clinical. Shaving Considerations If possible, use an electric shaver. Before shaving any client with a blade there are things you must do first. Because clients with clotting problems can bleed severely if shaved, the first thing you need to do is determine that the patient's clotting times are adequate . ...J Check labs (found on chart) for the following tests: 1. PT (Prothrombin Time, Protime) normal 9-12 seconds 2. APPT (Activated Partial Thromboplastin Time) normal 27-38 seconds 3. Platelet count 130,000-400,000 mm3 4. Also, check the client for signs of bleeding such as oozing around IV site, bruising, etc. 5. If you can't find the labs, call your instructor before shaving the client. Antiembolism Stockings & Sequential Compression Devices (SCD) .--Thigh Length Patients with limited movement or a risk for developing a deep vein thrombosis (DVT) may D Measure upper D .,. have an order for Antiembolism stockings thigh circumference at and/or sequential compression devices. If the glute 150 Procedure Checklist Providing Perineal Care Check ( .Y ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics, and documentation. 1. Assists with elimination as needed. 2. Fills the basin or perineal wash bottle with warm water (temperature should be approximately 105°F [41 °C] 3. Positions patient supine. 4. Places waterproof pads under patient. 5. Drapes patient for privacy: a. Female patient: Drapes legs and perineum using triangular-folded sheet or bath blanket. b. Male patient: Drapes chest with towel; drapes upper legs with another towel; leaves bed linens over lower legs. Exposes only perineum. 6. If the perineum is grossly soiled, places patient on a bedpan or portable sitz tub. 7. Removes any fecal material with toilet paper. 8. Moistens a washcloth with water in the basin or sprays perineum with the perineal wash bottle. 9. For females: a. Washes the perineum from front to back. b. Uses a clean portion of the washcloth for each stroke. c. Cleanses the labial folds and around the urinary catheter if one is in place. 10. For males: a. Retracts the foreskin, if present. b. Cleanses the head of the penis using a circular motion. c. Replaces foreskin and finishes washing the shaft of the penis, using firm strokes. d. Washes the scrotum, using a clean portion of the cloth with each stroke. e. Handles the scrotum gently to avoid discomfort. 11. Cleanses skin folds thoroughly, rinses, and pats dry. 151 Procedure Steps Yes No Comments 12. If perineal care is not being done as part of the bath, also cleans the anal area by asking the patient to turn to the side and washing, rinsing, and drying the area as needed. 13. Applies skin protectants as needed. Use powder only if patient requests it. 14. If patient has an indwelling catheter, provides special catheter care as prescribe by agency policy. Dons clean gloves before special catheter care. 15. Repositions and covers patient. 16. Removes and appropriately discards soiled gloves. Recommendation: Pass. ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 152 Procedure Checklist Bathing: Providing a Complete Bed Bath Check ( ;/ ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics, and documentation. 1. Uses warm, not hot, water (approximately 105°F [41°C]). 2. Changes water before cleansing the perineum and whenever the water becomes dirty or cool. 3. Adjusts the bed to working height. 4. Positions patient supine. 5. Drapes patient to provide privacy and prevent chilling. 6. Removes soiled linens without exposing patient. 7. Removes the patient's gown without exposing patient; exposes just the part of the body being bathed. 8. If patient has an IV, removes the gown first from the arm without the IV; replaces gown on the affected arm first; does not disconnect the IV tubing; keeps IV container above level of patient's arm. 9. Modifies the procedure or stops temporarily if patient becomes tired. 10. Follows principle of "head to toe". 11. Follows principle of "clean to dirty". 12. Washes extremities from distal to proximal. 13. While bathing patient, keeps loose ends of washcloth from dragging across the skin and wrings out excess water. 14. Supports joints when bathing. 15. Rinses well if using soap. 16. Pats dry to protect the skin. 17. Dries thoroughly between skinfolds. 18. Changes water and uses a clean washcloth to wash the perineal area. 19. Dons procedure gloves to wash the rectal area; removes any fecal matter with tissues before using a washcloth. 20. Applies deodorant, lotion, and/or powder as desired or as needed. 21. Provides a back rub if not contraindicated.,,, . Procedure Steps Yes No Comments 22. When finished, repositions patient and changes bed linen as needed. Recommendation: Pass, ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 154 Range of Motion ..... Skill oftheWeek Objectives & Activities • .. · • Be able to demonstrate and define flexion, extension, hyper extension, pronation, supination, abduction, abduction, internal rotation, external rotation, eversion, inversion, dorsi flexion, and plantar flexion. • Successfully perform range of motion for each of the following: elbow, knee, hip, wrist, ankle, shoulder, neck, fingers. Why? • To prevent joint contractu res and muscle atrophy due to immobility • To prepare an immobile client for ambulation • To maintain circulation, helping to prevent deep vein thrombosis Who? Anyone who is incapacitated, either by illness or operative procedures, who can't move around at least two hours every twenty-four. Types • ACTIVE - exercises the client can perform independently • ACTIVE-ASSISTED -exercises performed with some assistance • PASSIVE- exercises the client is dependent upon someone else to perform for them Method • Always be methodical and organized, don't jump from one part of the body to another, it'll confuse you and your client! • Never force a limb beyond what is comfortable! • Enjoy time with your client! To provide Passive ROM: 1. Verify orders, assess client for contraindications 2. Utilize correct body mechanics to avoid muscle strain to yourself and to your client including positioning the bed at correct height. 3. To protect client privacy expose only the limb being exercised. 4. Support the client's limb above and below the joint being exercised. 5. Move the body parts smoothly, slowly, rhythmically. Each exercise is usually done five times, twice a day. 6. Each exercise is done to the point of SLIGHT resistance, NOT to the point of pain. 155 Student Name· Date· Activity Date Instructor Exercises/Joint Motion - Mosby CO/Basic/Body Mechanics & Exercise Skill Check off: Passive Range of Motion Exercises 5 Comments 1. Determine any restrictions for passive range-of-motion exercises. Plan time for exercises to be done several times a day. 2. Wash hands, check pt. 10, provide privacy & explain procedure to client. 3. Elevate the bed and place the client in semi Fowlers position. 4. Start at head and do exercises down each side of body. Repeat each exercise five times, supporting the appropriate joints. Head: Turn side to side; tilt chin toward sternum, then turn to normal position; tilt head upward (occiput toward spine); tilt each ear to shoulder. Neck: Rotate neck in semicircle. Truck: Bend trunk forward straighten, and extend slightly backward; turn shoulders forward, then relax; tip trunk to left, then right. Arm: Extend arm to head, then along side; extend toward midline (adduction) and away from midline (abduction). Shoulder: Bend elbow at 90° angle, keeping upper arm parallel to shoulder; move lower arm upward and downward. Elbow: Flex and extend elbow; move hand in palm up then palm down position. Wrist: Flex and extend wrist; Turn wrist to right, then left, rotate wrist in circular motion. Hand: Flex and extend fingers; spread fingers apart, then together; touch each finger with tip of thumb. Thumb: Rotate thumb in circular motion. Hip and leg: Flex leg toward chest, then extend; move extended leg away from body (abduction/adduction). Knee: Flex and extend knee. Ankle: Flex and extend ankle. Foot: Spread toes apart; then together; extend toes upward, then downward. 5. Provide safety & positioning. Perform hand hygiene. 6. Evaluate client tolerance & document procedure in medical record Complete within 15 per agency policy. minutes. Check off by: __---c;;;-:---:----- Check off by: ___=-,...... ,------Student Evaluator Date: ______Date: ______ 156 Positioning, Transfer & Ambulation . . Skill ofthe Week Objectives & Activities . . • Describe the procedures for assisting a client to move up in bed, reposition a helpless client, assisting a client to a sitting position, and transferring a client from a bed to a chair, wheelchair, or commode. • Perform proper positioning: supine, prone, Fowlers (high, semi}, lateral, Sims. • Perform proper transfer from bed to chair/wheelchair • Assist with ambulation in lab/clinical setting using gait belt & mechanical lift unilateral and generalized weakness • Demonstrate appropriate technique for crutch walking (2 point, 3 point, 4 point, swing thru) Back Safety & Transfer Training Introduction: 1. Everyone experiences back pain at some time in their lives, especially health care workers. 2. Starts with improper lifting and moving, leading to unnecessary stress to the back, injury, and chronic pain. Most are preventable. 3. Once injured, re-injury much more likely. 4. Visit www.osha.gov for more guidelines and details. Risks: 1. Depends on knowledge of back anatomy, body mechanics, transfer training, and self-care. 2. Ask, do 1...... maintain the natural spinal curves? ... know which muscles are needed for transferring and moving? ... use my body weight to transfer, not my back? ... keep my clients close to my center of gravity? ... ask for help? ... get organized to know what to do as I begin transferring? ... understand my client's special needs? ... know how to use assistive devices? ... exercise regularly? ... keep healthy and physically fit? ... take regular breaks? ... take care of myself? 157 General Guidelines (Michelle Preston-Smith, MS, PT) 1. Assess the client before lifting or moving. 2. Eliminate or reduce manual lifting and moving of clients. 3. Have client help as much as possible, giving clear and simple instructions, allowing for adequate time for response. 4. Get help whenever possible. a. Use teamwork, make sure your team members are adequately trained, understand proper lifting technique and use timing. 5. Plan and prepare. 6. Set up surfaces to keep work tasks, equipment, and supplies close and at the correct height- between waist and shoulders. 7. Make sure brakes are working properly, and make sure you apply them firmly. 8. Use upright, neutral postures and proper body mechanics. a. Bend legs, not back. b. Don't twist. Pick up feet and pivot whole body. c. Always face the load, and pull it toward your center of gravity. d. Use the "ugly- butt" and do not curve your back. Assistive Devices 1. Draw Sheets- Make sure the client is supported from thigh to shoulder. Used to protect client's skin by reducing friction. 2. Trapezes- Allow client to assist with moving in bed. Adjust the length of the chain so that the client's elbows are slightly bent when grasping the bar. 3. Slide Boards- Scoot enough of the board under the client; ensure client's skin is protected. a. Sitting slide boards - client must have fair sitting balance. Must use gait belt to assist client and for safety. b. Supine slide boards- use when client unable to tolerate sitting board. c. Plastic bags - large plastic bags over the boards make a smoother surface. Be aware this makes the surface very slippery! 4. Gait Belts - Make sure the belt fits snuggly around the client's waist. Be aware of G tubes, colostomy bags, surgical sites, fractured ribs, etc. 5. Mechanical Lifts- Use with clients who are unable to assist with the transfer or are obese. Be sure that the sling is properly supporting the client, that you understand how to use the lift, and that you have at least one other person to assist. Special Needs Clients 1. Frail- Remember to use smooth, slow, and controlled movements. Talk through the transfer so the client knows what to expect. 2. Obese - Because of their size, these clients are harder to move and put you at higher risk for injury. Have the client help as much as possible, use double sheets as a precaution or use a mechanical lift. 3. Paralyzed- Protect paralyzed extremities, because often the client is unable to do so. Move body by parts or sections, i.e. body-on-body rolling. 4. Tubes - Check every client for tubes. Place tubes, catheter bags, IV poles, etc. in the direction of the move to avoid pulling or tangling. 158 5. Casts- Remember that casts add extra weight to transfers and the client is often unable to lift the part. Get help to move the cast and use an over bed trapeze. 6. Traction- Movement is often painful, use slow, controlled movements to minimize discomfort. Leave the traction unit intact, do not lift the weights. Lifting • Use upright, neutral working postures and proper body mechanics. • Keep client, equipment, and supplies close to the body with hand holds between the waist and shoulders. • Move the client towards you, not away from you. • Use slides and lateral transfers instead of manual lifting. • Use a wide, balanced stance with one foot slightly ahead of the other. • Lower the client slowly by bending your legs, not your back. Return to and erect position as soon as possible. • Use smooth movements and do not jerk. When lifting with others, coordinate lift by counting down and synchronizing the lift. Lateral Transfers • Position surfaces as close as possible to each other. Surfaces should be at approximately waist height, with the receiving surface slightly lower to take advantage of gravity. • Lower side rails on both surfaces. • Use draw sheets or incontinence pads in combination with other friction reducing devices (slide boards, sheets, plastic bags, etc.) • Get a good hand-hold by rolling up draw sheets and incontinence pads or use devices with handles. • Kneel on the bed or gurney to avoid extended reaches and bending the back. Have team members on both sides of the surfaces. Count down and synchronize the lift. Use a smooth, coordinated push-pull motion. Do not reach across the person being moved. Gait Belts • Keep the client as close as possible. • Assisting with ambulation • Avoid bending, reaching or twisting you • Pivot with your feet to turn back when: • Use a gentle rocking motion to take • Attaching or removing belts advantage of momentum. • Lowering the client down Stand Pivot Transfer- Bed to Chair Assess: Strength Sensory status Joint mobility Motivation Orthostatic hypotension Previous mode of transfer Activity tolerance Risk for falling Level of comfort Client's ability to assist - If unable vs get help! 159 Guidelines for Transporting Clients and Equipment • Decrease load or weight of carts, instrument trays, etc. • Store items and equipment between waist and shoulder height. • Use sliding motions or lateral transfers instead of lifting. • Push, don't pull. Keep loads close to your body. Use an upright, neutral posture and push with your whole body, not just your arms. • Move down the center of corridors to prevent collisions. • Watch out for door handles and high thresholds which can cause abrupt stops. Principles of Body Mechanics 1. Use your LEGS 2. Keep your BACK STRAIGHT 3. DON'T TWIST 4. Move your feet; FACE THE LOAD 5. Keep the load CLOSE 6. SIZE UP the load 7. Ask for HELP if the load can't be managed alone 160 Degrees of Assistance Defined Independent Client able to begin & complete tasks without physical assistance & without verbal cues. a. Dressing - client must be able to retrieve clothes safely and independently. b. Bathing- client must be able to set up own bath. Modified Adaptive devices ensuring independence should be Independent documented, i.e. client independent with dressing using long handled shoe horn. Supervised Client able to begin and complete task without physical assistance. May require verbal cues for sequencing or safety. Care provider is in close proximity. Standby Client able to begin and complete task without physical Assistance assistance. May require verbal cues for sequencing or safety. Care provider stands next to the client for assistance. Contact Guarding Client able to begin and complete the task but requires light "hands on" assistance, i.e. light touch on shoulder to bring body forward when changing from sitting to standing. Minimal Client able to contribute most of the effort to accomplish tasks Assistance and requires constant physical assistance (75% done by client, 25% done with assistance). Moderate Client able to contribute half of the effort to accomplish the task Assistance and requires constant physical assistance. Maximal Client may or may not be able to contribute minimal effort to Assistance initiate and/or complete tasks and requires the majority of physical effort by others or with the use of mechanical assistance (25% effort by client). Precautions for Total Hip Arthroplasty 1. NO hip flexion greater than 90 degrees (lifting knee toward chest or bending over) 2. NO internal rotation (knees facing each other, or pigeon-toed position) 3. NO hip adduction past neutral (crossing legs, or side-lying with legs moving past midline) 161 Procedure Checklist Transferring a Patient from Bed to Chair Check ( .Y ) Yes or No Procedure Steps Yes No Comments 1. Determine the need for transferring the patient from a bed to a chair 2. Wash hands 3. Positions the chair next to the bed and near the head of the bed. If possible, locks the chair 4. Puts nonskid footwear on the patient 5. Applies transfer belt 6. Places the bed in low position 7. Assists patient to dangle at bedside 8. Faces the patient; brace feet and knees against patient's feet and knees. Pays particular attention to any weaknesses 9. Bends hips and knees; holds onto the transfer belt. If two nurses are available, one nurse should be on each side of the patient 10. Instructs patient to place his or her arms around the nurse between the shoulders and waist (the exact location depends on the height of the nurse and the patient) 11. Asks the patient to stand as the nurse moves to an upright position by straightening her legs and hips 12. Allows the patient to steady his or herself for a moment 13. Instructs the patient to pivot and turn with the nurse toward the chair 14. Asks the patient to flex her hips and knees as she lowers his or herself to the chair. Guides her motion while maintaining a firm hold of the patient 15. Assists the patient to comfortable position in the chair. Provides blanket, if needed 16. Provide patient with call light 17. Wash hands 18. Document procedure 162 Recommendation: Pass______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 163 Procedure Checklist Use of a Patient Mechanical Lift Check ( -.J ) Yes or No Procedure Steps Yes No Comments 1. Determine the patient's need for the use of the mechanical lift 2. Wash hands 3. Gather supplies (including the mechanical lift) 4. Wash hands upon entering patient room 5. I. D. patient 6. Explain procedure 7. Provide for privacy 8. Places patient in a comfortable position that provides efficient use of the mechanical lift 9. Dons clean gloves 10. Raise bed to a level that will not place strain on the nurse's back 11. Roll the patient onto his or her side and position the sling The sling should underneath patient extend from behind the knees to beyond the patient's head 12. Smooth out the sling material and roll the patient onto his or her back 13. Get mechanical lift ready by pushing the base of the mechanical lift under the bed 14. Press lever down to lock base of the mechanical. Mechanical lift must be in a locked position when in use 15. Lower bed and side rails 16. Attach sling to lift by hooking the four sling straps to the four hooks on the cradle 17. Slightly raise the patient until his or her body clears the bed 18. Unlock the mechanical lift and move the lifted patient 19. Position the sling of the mechanical lift over a chair or The sling should wheelchair (center the sling over the chair or wheelchair). be positioned in a way that the patient should end up in a sitting position in the wheelchair 164 Procedure Steps Yes No Comments 20. Open the control valve on the mechanical lift to lower the patient into the chair or wheelchair 21. Have one nurse guide the patient's body into the wheelchair while the second nurse is controlling the movement of the mechanical lift 22. Make sure that the breaks are applied on the wheelchair prior to lowering the patient into it 23. When the patient is positioned correctly in the chair or wheelchair, disconnect the straps from the lift, leaving the sling under the patient 24. Move the mechanical lift to a safe place for use later 25. Provide comfort measures 26. Provide patient with call light 27. Wash hands 28. Document procedure Recommendation: Pass ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 165 Student· Date· Activity Date Instructor Body Mechanics & Exercise - Mosby CO/Basic Skill Check off: Positioning a Client in Bed s Comments 1. Determine appropriate position & assistance needed. Gather Draw sheet, pillows. appropriate equipment. 2. Wash hands 10 client, provide privacy, & explain procedure. 3. Elevate bed to working height & place draw sheet under client's back (shoulder to knees) Fowler's Position f"; (: i 0 Hips even with the middle of the bed, place bed at a 45' to 90° angle. !.-----"-··-../ ------....) • Small pillow at small of back, pillow under ankles, arms, & head Semi-Fowlers 45-60 Hioh-Fowlers 60-90 Supine Position I; Bed flat. Small pillow at small of back, pillow under head & ankles . • Assess heels for redness Side-Lying Position ~I\_ /I • Roll client to side. Place pillow under head, behind back, between legs, \ and tucked by abdomen. Move dependent shoulder forward. Sims Position 0 Roll client toward abdomen with dependent shoulder, arm, hip & leg pulled back. Place pillow under head, tucked under abdomen, under top leg, & ~ under top arm Prone Position 0 Client on abdomen. Place small pillow under head. Turn head to side. ~ Extend arms near side or fiex toward head. Place pillow under ankles or allow toes to rest between foot of bed & mattress. 4. Assess client for comfort. Lower the bed & elevate side rails. At least every 2 Evaluate frequency of repositioning. hours 5. Document actions/findings/client tolerance: Complete within 15 minutes. Check off by: ___=-..,.------Check off by: ___-=-..,.--,.------Student Evaluator Date: ______Date: ______ 166 Urine Sample- Foley (Sterile), Clean Catch . . Skill ofthe Week Objectives & Activities • Demonstrate sterile urine sample collection from Foley catheter • State patient instructions to safely obtain clean catch urine sample for a male & female • Describe safe/effective handling, storage and correct amounts of urine samples • State normal urine appearance pH, specific gravity, glucose, acetone Urinalysis - clean catch First voided spec in am if possible to ensure uniform concentration of constituents Nurse can do quick screening with reagent strips What is measured? • Specific Gravity (N=1.01 0-1.025) => Substance concentration compared to equal volume of water => Aids in determination of fluid balance: => High-concentrated - dehydration => Low-dilute- over hydration • pH (N=4.6- 8) => Acid pH protects against bacteria • Protein (N=up to 8mg/1 OOml) => Damage to glomeruli or tubules (Renal Failure) allows protein to enter urine • Glucose (N=O) => Inability of tubules to reabsorb high glucose concentrations (diabetes) => Seen in healthy with heavy ingestion of glucose • Ketones (N=O) => End product offat metabolism => Seen in dehydration, starvation, excessive use of aspirin • Blood (RBC- N=O; WBC- N=0-4) => Renal damage, trauma, disease, surgery, UTI • Bacteria (N=none) =>UTI 167 Procedure Checklist Obtaining a Clean-Catch Urine Specimen Check ( --1 ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, body mechanics. Note: If patient can do self-care, instructs patient in the following steps. If not, performs them for patient. 1. Dons clean procedure gloves. 2. Opens the prepackaged gloves. 3. Washes hands and don clean procedure gloves. 4. Cleanses, or instruct patient to cleanse, around the urinary meatus. Allow the area to dry. Variation: For Women: a. Washes the perineal area with warm water and mild soap if soiled. Otherwise, instructs use of an antiseptic towelette. b. Opens the antiseptic towelette provided in the prepackaged kit. If there is no kit, pour the antiseptic solution over the cotton balls. Wipes down one side of the meatus using one pad and discard it. Then wipes the other side with a second pad. Wipes down center over the urinary meatus with the third pad; then discard it. Cleans the perineal area at least twice. Uses each towelette or cotton ball only once. Variation: For Men: c. If the penis is uncircumcised, retracts the foreskin back from the end of the penis. d. Uses the towelette provided in the prepackaged kit or pour antiseptic solution over cotton balls or a 2 in. x 2 in. gauze pad soaked with povidone-iodine, if patient is not allergic to iodine. e. With one hand, grasps the penis gently. With the other hand, cleanses the meatus in a circular motion from the meatus outward, and cleanses for a few inches down the shaft of the penis. Cleanses around the meatus at least twice, using each towelette or cotton ball only once. Repeats the cleansing three times, each time with a fresh 2 in. x 2 in. gauze pad, towelette, or cotton ball. 5. Removes gloves. Washes hands, and dons the second pair of clean procedures gloves. 168 Procedure Steps Yes No Comments 6. Opens the sterile specimen container, being careful not to touch the inside of the lid or container. 7. Holding the container near the meatus, instructs patient to begin voiding into the container. Holds the female labia apart during this step (or teaching self-care patients to do so). For the male patient who is unable to assist, holds the penis during voiding. 8. Allows a small stream of urine to pass; and then without stopping the urine stream, places the specimen container into the stream, collecting approximately 30-60 ml. 9. Removes the container from the stream, and allows patient to finish emptying his bladder. Note: If the penis is uncircumcised, replaces the foreskin over the glans when the procedure is finished. 10. Carefully replaces the container lid, touching only the outside of the cap and container. Avoids touching the rim of the cup to the genital area. Does not get toilet paper feces, pubic hair, menstrual blood, or anything else in the urine sample. 11. Labels the container with the correct patient information (in many institutions, labels are preprinted or bar-coded). Places the container in a facility-specific carrier (usually a plastic bag) for transport to the lab. 12. Removes gloves and washes hands. If the specimen has been obtained from a patient on a bedpan, leaves gloves on until it is removed, emptied, and stored properly. 13. Assists patient back to bed, or removes the bedpan, if applicable. (See Procedure 28-2 for removing a bedpan). 14. Transports the specimen to the lab in a timely manner. Recommendation: Pass ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 169 Procedure Check List Obtaining A Sterile Specimen From A Foley Catheter Student Name· Date· ·· ...... •...... ·.. · ·. t#c$km Check off: Positionin~:~···a.•rg.!i~!lt,!ni'3,.E!d 5 Corfi•mehts . ·•· 1. Determine appropriateness, verify orders. 2. Gather appropriate equipment: Access to the closed system is by Gloves, clamp, sterile specimen cup, Biohazard bag, label, needleless port. lab requisition, alcohol wipes, 10 ml syringe 3. Wash hands, ID client, provide privacy, explain procedure. 4. Manipulate the drainage tubing so that urine in tubing goes into bag. Clamp tubing below aspiration port for 15-30 minutes. 5. Prepare specimen cup & remove cap. Apply gloves. Cleanse aspiration port with antiseptic solution and let dry. Secure syringe to access port, aspirate 10 ml of urine. 6. Transfer urine to labeled container, seal, and place in biohazard bag. Place syringe in sharps container or designated biohazard container. Remove clamp & gloves and wash hands. 7. Evaluate patency of closed urinary drainage system before leaving client's room. 8. Document actions/findings/client tolerance: Specimen must be transported to lab with 15 minutes or refrigerate. Complete within 10 minutes. Check off by: __---c;:;;-:;-:-:-;----- Check off by: ___=--,-,------Student Evaluator Date: ______Date: ______ 170 J Hot & Cold Applications Skill of th~ W~~k Obj~ctives & Activities • Understand normal body responses to local temperature variation • Know local effects of heat and cold • List conditions that increase risk from heat and cold application • List therapeutic effects of heat and cold application • Determine how to assess for temperature tolerance • List safety factors for applying heat or cold • Compare/contrast moist and dry application methods • Demonstrate how to apply warm soaks, ice packs, and use thermal pads safely Risks • Impaired circulation: Diabetes, peripheral vascular disease (PVD), arteriosclerosis • Decreased ability to note discomfort: age, confusion, unconsciousness, spinal cord injury Safety Factors • Check skin for breaks, stomas, edema, scar formation, impaired circulation • Assess for alertness, cooperation, sensation • Equipment safety Moist/Dry Application Methods • Moist: Compress/pack, soaks, sitz bath, K pad • Dry: blower, heat lamp, commercial hot packs Effects • Warm soaks: cause vasodilation & increase tissue blood flow • Ice packs: cause vasoconstriction, local anesthetic, blood coagulation Thermal pads: electronic method for administering hot or cold 171 Student Name· Date· . Skill Check off: Hot/Cold Applications s Comments 1. Verify orders, determine appropriateness & gather Assess for sensation, equipment. color, tissue damage, bleeding. 2. Wash hands, ID client, provide privacy & explain procedure. 3. Assess site for skin integrity, circulation, movement, Apply gloves if skin not sensation intact Cold Applications Fill bag or collar 2/3 full with ice and expel air. 0 Prepare cold pack & cover with towel or cover sleeve Activate pack. Apply to affected area . Temperature about • 59' F. • Place pack over affected area & secure . Leave pack in place for 20-30 minutes if client tolerates . Check periodically to • ensure tolerance. Hot Applications Temperature about 105-113'F. • Prepare warm pack (moist or dry) & cover with towel. Place over affected area for no more than 30 minutes . Assess client tolerance • periodically. K-Pad Applications Verify adequate distilled water Prepare warm or cold application using k-pad. (dry or • Set temperature moist). 4. Reassess after 5 minutes 5. Remove after no more than 30 minutes, reassess 6. Dispose of single use items, assess site, remove/clean equipment & perform hand hygiene. 7. Document actions/findings/client tolerance: Identify hazards of using hot & cold therapies. What patients are at risk? Check off by: ___::c--:--,------Check off by: ___=-.,.------Student Evaluatar Date: ______Date: ______ 172 Blood Glucose Testing & Monitoring . . Skill of the Week Objectives & Activities • Identify steps for safe nursing care when clients need blood glucose testing. • Demonstrate accurate blood glucose testing. • Describe appropriate interventions once blood glucose levels have been determined. (Blood Sugar, Fasting Sugar (FBS) Normal Value Clinical Priorities 6 Serum glucose levels must be evaluated according to Child-2 years to the time of day they are obtained. Increased levels adult: follow a recent meal. 80-120 mg/dl 6 Glucose determinations must be performed frequently in new diabetic patients to determine Critical Value appropriate insulin therapy. Finger stick blood <40 and >400 glucose determinations are often performed before mg/dl meals and at bedtime. 6 Many forms of stress can cause increased serum glucose levels. Trauma, general anesthesia, infection, burns, myocardial infarction. 6 Many drugs affect glucose levels. ,.... antidepressants (tricyclics), beta-adrenergic blocking agents, corticosteroids, caffeine, IV fluids contain dextrose, which is quickly converted to glucose ...., acetaminophen, alcohol, insulin, popranolol 6 Many pregnant women experience some degree of glucose intolerance. If significant it is called gestational diabetes. 173 Procedure Checklist Checking Fingerstick (Capillary) Blood Glucose Levels Check ( -.f ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, and body mechanics. 1. Instructs patient to wash her hands with soap and warm water, if she is able. Dries completely. 2. Turns on the glucose meter. Calibrates according to the manufacturer's instructions. 3. Checks the expiration date on the container of reagent strips. 4. Checks that the reagent strip is the correct type for the monitor being used. 5. Dons procedure gloves. 6. Removes the reagent strip from container; tightly seals the container. 7. Places reagent strip into the glucose meter. 8. Selects a puncture site on the lateral aspect of a finger (heel or great toe for an infant) and cleans the site with alcohol pad (according to facility policy). Lets dry completely. 9. Uses a different site each time glucose is checked. 10. Positions the finger in a dependent position and massages toward the fingertip. 11. For infants, older adults, and people with poor circulation, places a warm cloth on the site for about 10 minutes before obtaining the blood sample. 12. Performs fingerstick: a. Engages the sterile injector and removes the cover. b. Places a disposable lancet firmly in the end of injector. c. Places the back of the hand on the table, or otherwise secures the finger so it does not move when pricked. d. Positions the injector firmly against the skin, perpendicular to the puncture site. Pushes the release switch, allowing the needle to pierce the skin. e. If there is no injector, uses a darting motion to prick the site with the lancet. 13. Lightly squeezes patient's finger above the puncture site until a droplet of blood has collected. 174 Procedure Steps Yes No Comments 14. Places a reagent strip test patch close to the drop of blood. Allows contact between the drop of blood and the test patch until blood cover the entire patch. Does not "smear" the blood over the reagent strip. 15. Places the reagent strip into the glucose meter, if not already inserted. (Follows individual manufacturer instructions). 16. Allows the blood sample to remain in contact with the reagent strip for the amount of time specified by the manufacturer. 17. Using a gauze pad, gently applies pressure to the puncture site. 18. After the meter signals, reads the blood glucose level indicated on the digital display. 19. Turns off the meter and disposes of the reagent strip, cotton ball, gauze pad, paper towel, alcohol pad, and lancet in the proper containers. 20. Removes the procedure gloves and disposes of them in the proper container. Recommendation: Pass. ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 175 Oxygenation, Airways, Nasal Cannulas, Masks . . Skill of the Week Objectives & Activities . • Correctly identify, and apply mask, re-breather mask, and nasal cannula • Correctly define pulse oximetry and its purpose. • Demonstrate oral/nasal airway insertion. • Demonstrate correct use of ambu bag. Oxygenation: Oxygen ordered by physician. At times there may be a range ordered according to oxygenation saturations or a unit/facility protocol. Too high an oxygen flow rate in any patient can stimulate changes in the lung tissue causing a decrease in diffusion, check your oxygen flow meters and orders for each patient. Patients with COPD are used to high PaC02 levels in their blood. Too much oxygen (over 1-2 Umin) can take away their drive to breath, as a lack of oxygen has become their breathing trigger rather than a high C02 level. Oxygen can be ordered by the liters per minute (Lim in) or by the % of oxygen in inspired air. In normal room air breathing 21% oxygen reaches the lungs. Airways: • Choose oral or nasal & measure from the tip of nose (nasal) or corner of mouth (oral) to the earlobe Nasal Cannulas: • Is effective for mouth breathers because oxygen is heavier than room air. • Can accommodate oxygen up to 6 Umin. Flow rates > 4Limin rarely used because they dry out the mucosa and do not increase the actual oxygen concentration inspired. • Need to humidify the oxygen with sterile distilled water. Check the humidifier when you check the oxygen and replace as needed. Masks: Oxygen masks are used to administer oxygen, humidity, or heated humidity. Simple Face Mask • For short term oxygen therapy • Not a good idea to use these with C02 retention patients (COPD) ~l,,.";••'"- /1 o Provide 30-60% OX'VQEln····· -·"' Re-breather Mask - Can provide 70% oxygen when used at 10 Lim in Reservoir/Non-re-breather Mask - 80-90% oxygen at 10 Lim in Venturi Mask • The percentage of oxygen depends on the flow rate attached to it. • Highest is 55% (14 Umin), lowest 24-30% (2-3 Llmin) 176 Student Name· Date· . ·Activity Date Instructor Oxygenation- Mosby CO/Intermediate Skill C.heck off: Oxygen Administration ·. 5 Comments (Airway/Ambu/Nasai/Mask) ·. 1. Determine appropriateness of administration type, verify orders, & perform hand hygiene. Gather appropriate equipment. Wash hands, ID client, provide privacy, & explain procedure. Oral/Nasal Airway 2. Select appropriate type/size (nasal/oral); Insert into mouth/nares correctly Ambu Bag 3. Attach to 02 source & mask; Administers breaths Nasal Cannula 4. Attach nasal cannula to humidified oxygen source & adjust oxygen flow to prescribed rate. 5. Place tips of cannula into nares & adjust until cannula fits snugly and comfortably. Perform hand hygiene. Mask 6. Select correct size & apply correctly, adjust for fit 7. Document actions/findings/client tolerance: Follow up Assessment • Check oxygen flow rate and physician's orders every 8 hours . • Inspect client for relief of symptoms . 0 Observe nares and superior surface of ears for skin breakdown. • Assess pulse oximetry readings with VS or as ordered . Check off by: __---:::-:-:--:----- Check off by: ___=-:--:------student Evaluator Date: ______Date: ______ 177 Enemas . .. . . Skill ofthe Week Objectives & Activities • Explain what an enema is and its purpose • State the suggested maximum volume for an enema in an adult • State procedure and rationale for cleansing enema, tap water enema, oil retention enema, Harris flush, and medicated enemas • Assemble correct equipment, position client correctly, and follow procedure for administering a cleansing enema • Correctly place client on a bedpan after enema administration • Correctly document the administration of, effect and results of a cleansing enema Types: Cleansing • tap water • normal saline • soap solutions (1 tsp castile per 1000 cc) • Low volume hypertonic (fleets) Oil Retention Carminative • MGW or 1-2-3 (30 ml magnesium, 60 ml glycerine, 90 cc water) • Return flow-Harris flush Medicated • Kayexalate • Neomycin Administration: Note: tip insertion on adult is 3-4 inches Height of container is 12-18 inches for high enema Height of container is 12 inches or less for a low enema Maximum volumes for an adult are 750-1000 cc Enemas till clear - indicates no more fecal matter, not that water is clear. No more than three or less if patient not tolerating Patient who is unable to contract the external sphincter: put on bedpan, but never administer an enema on commode or toilet. Digital removal of stool: check hospital policy, use caution, watch for bleeding. 178 Procedure Checklist Administering an Enema Check ( --1 ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, and body mechanics. 1. Determines patient's ability to retain the enema solution. 2. Places a bedpan or bedside commode nearby for patient with limited mobility. 3. Opens the enema kit or obtains supplies. 4. Warms the solution to 105°-110°F (40°-43°C), not in a microwave. Checks temperature with bath thermometer. 5. Attaches tubing to the enema bucket if a bucket is being used (the 1-L enema bag comes with preconnected tubing). 6. Closes the clamp on the tubing and fills the container with 500-1100 ml of warm solution (40-150 ml for infants; 250- 350 ml for toddlers; 300-500 ml for school-age children.) 7. Adds castile soap or soap solution used by the facility, if a soapsuds enema was prescribed. 8. Hangs the container on the IV pole. 9. Holding the end of the tubing over a sink or waste can, opens the clamp and slowly allows the tubing to prime (fill) with solution. Reclamps when filled. 10. Dons clean procedure gloves. 11. Asks patient to turn or assists to turn to a left side-lying position with the right knee flexed. (Elevates head of the bed very slightly for patients who have shortness of breath). 12. Places a waterproof pad under patient's buttocks/hips. 13. Drapes patient with bath blanket, leaving only the buttocks and rectum exposed. 14. Places the bedpan flat on the bed directly beneath the rectum, up against patient's buttocks; or places the bedside commode near the bed. 15. Generously lubricates the tip of the enema tubing. 16.1f necessary, lefts the superior buttock to expose the anus. 17. Slowly and gently inserts tip of the tubing approximately 7-10 em (3-4 in.) into rectum; asks patient to take slow, deep breaths during this step. 18. If tube does not pass with ease, does not force, allows a small amount of fluid to infuse and then tries again. "" Procedure Steps Yes No Comments 19. Removes the container from the IV pole and holds it at the level of patient's hips. Begins instilling the solution. 20. Slowly raises the level of the container so that it is 30-45 em (12-18 in.) above the level of the hips. Adjusts the IV pole and rehangs the container. 21. Continues a slow, steady instillation of the enema solution. 22. Continuously monitors patient for pain or discomfort. If pain occurs or resistance is met at any time during the procedure, stops and consults with the primary care provider. 23. Assesses ability to retain the solution. If patient has difficulty with retention, lowers the level of the container, stops the flow for 15-30 seconds, and then resumes the procedure. 24. When the correct amount of solution has been instilled, clamps the tubing and slowly removes the tubing from the rectum. 25. If there is stool on the tubing, wraps the end of the tubing in a washcloth or toilet tissue until it can be rinsed or disposed of. 26. Cleanses patient's rectal area. 27. Re-covers patient. 28.1nstructs patient to hold the enema solution for 5-15 minutes. 29. Places the call light within reach. 30. Disposes of enema supplies or, if reusable, cleans and stores in an appropriate location in patient's room. 31. Removes gloves; washes hands. 32. Depending on patient's mobility status, assists onto the bedpan, to the bedside commode, or to the toilet when she feels compelled to defecate. 33. After patient has defecated, inspects the stool for color, consistency, and quantity. 180 Procedure Checklist Administering an Enema (continued) Check ( ...J ) Yes or No Procedure Steps Yes No Comments Prepackaged Enemas: 1. Determines patient's ability to retain the enema solution. 2. Places a bedpan or bedside commode nearby for patient with limited mobility. 3. Warms the solution-not in a microwave. 4. Dons clean procedure gloves. 5. Asks patient to turn or assists to turn to a left side-lying position with the right knee flexed. (Elevates head of the bed very slightly for patients who have shortness of breath). 6. Places a waterproof pad under patient's buttocks/hips. 7. Drapes patient with bath blanket, leaving only the buttocks and rectum exposed. 8. Opens prepackaged enema. Removes the plastic cap from the container. The tip of the prepackaged enema container comes prelubricated. Adds extra lubricant as needed. 9. If necessary, lifts the superior buttock to expose the anus. 10. Slowly and gently inserts tip of the tubing approximately 7-10 em (3-4 in.) into rectum; asks patient to take slow, deep breaths during this step. 11. If tube does not insert with ease, does not force; removes, relubricates, and retries. 12. Tilts container slightly and slowly rolls and squeezes the container until all of the solution is instilled. 13. Withdraws container tip from the rectum; wipes the area with a washcloth or toilet tissue. 14. Cleans patient's rectal area, re-covers patient and instructs to hold the enema solution for approximately 5-10 minutes. 15. Removes gloves; washes hands. 16. Places the call light within reach. 17. Disposes of the empty container. 18. Depending on patient's mobility status, assists onto the bedpan, to the bedside commode, or to the toilet when she feels compelled to defecate. Return-Flow Enemas: 1. Obtains rectal tube and solution container. 181 Procedure Steps Yes No Comments 2. Places a bedpan or bedside commode nearby for patient with limited mobility. 3. Prepares 100 to 200 ml tap water or saline. Warms the solution to 105°-110°F (40°-43°C), not in a microwave. Checks temperature with bath thermometer. 4. Attaches tubing to the enema container and primes the tubing. 5. Dons clean procedure gloves. 6. Asks patient to turn or assists to turn to a left side-lying position with the right knee flexed. (Elevates head of the bed very slightly for patients who have shortness of breath). 7. Places a waterproof pad under patient's buttocks/hips. B. Drapes patient with bath blanket, leaving only the buttocks and rectum exposed. 9. Generously lubricates the tip of the enema tubing. 10. If necessary, lifts the superior buttock to expose the anus. 11. Slowly and gently inserts tip of the tubing approximately 7-10 em (3-4 in.) into rectum; asks patient to take slow, deep breaths during this step. 12. If tube does not insert with ease, does not force; allows a small amount of fluid to infuse and then tries again. 13. Holds the container at the level of patient's hips. Begins instilling the solution. 14. Slowly raises the level of the container so that it is 30-45 em (12-1 B in.) above the level of the hips. 15. Continues a slow, steady instillation of the enema solution. 16.1nstills all the solution into patient's rectum. 17. When the correct amount of solution has been Lowers the tube and container below the level of the rectum and allows the solution to flow back into the container. 1B. Repeats instillation and return several times or until distention is relieved. 19. Withdraws container tip from the rectum; wipes the area with a washcloth or toiler tissue. 20. If there is stool on the tubing, wraps the end of the tubing in a washcloth or toilet tissue until it can be rinsed or disposed of. 21. Removes gloves; washes hands. 22. Places the call light within reach. 23. Disposes of the empty container. 182 Recommendation: Pass, ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 183 Physical Assessment (LPAT) Skill of the Week Objectives.& Activities • List the purposes of physical assessment • Define inspection, palpation, percussion, auscultation • List techniques used to promote the client's physical and psychological comfort during an exam • List normal physical findings in an adult • Demonstrate placement of stethoscope for auscultation of breath sounds, bowel sounds, apical heart rate • Be aware of anterior, lateral, and posterior position of lung lobes in relation to anatomical landmarks LPAT & KATZ Mini-mental forms available on website Student Name: ______Date: ______ Skill Check off: LPAT s Comments · .. 1. Neurological 2. HEENT 3. Respiratory show proper placement of stethoscope for auscultation of all lobes (anterior & posterior) Explain/demonstrate the most effective method for auscultation. 4. Cardiovascular show proper placement of stethoscope for PMI 5. Gastrointestinal show proper placement of stethoscope and order for bowel sounds Explain hyper, hypo, and absent bowel sounds 6. Genitourinary How much urine is normal for an hourly average? 7. Musculoskeletal 8. Psychosocial Complete within 15 minutes Check off by: __---c;;-;-;--;----- Check off by: ___;::-;--;------Student Evaluatar Date: ______Date: ______ 184 Merced College Registered Nursing -REG 15 Leveled Physical Assessment Tool (LPAT) 1st semester- Inspection & Auscultation Date: ___ Pt. 10: __ Room#: height: __ weight: BMI: -- Vital Signs: T ___ P R BP ___ 02 sat. % Pain /10 T p R BP ___ 02 sat. % Pain· /10 T p R BP ___ 02 sat. % Pain /10 NEUROLOGIC Level of Consciousness (LOG): Alert Lethargic I Stuporous I Comatose Level of Orientation: x 4 Person I Place I Time I Purpose Pain: none present (location): ,------Sleep pattern: nonnal for self abnonnal (describe): ______. HEENT (head, eves, ears, nose, and throat) -,,,. Head: shape nonnocephalic asymmetrical Hair: clean I shiny dirty I dull/ fine I coarse Eyebrows I Eyelashes: present absent Eyes : sclera white red I yellow I brown vision nonnal glasses I contacts '"' Ears: hearing nonnal (low voice) HOH I Deaf or Hearing ·aid: AD AS AU Nose: nares patent non-patent I deviated septum I bloody Mouth: lips intact cracked I swollen tongue clean coated mucous membranes moist dry dentition good poor /loose I edentulous I dentures: upper /lower I both Throat: swallowing smooth dysphagia speech clear aphasia RESPIRATORY Rhythm I Depth I Quality reg. I nml. I unlabored irregular I deep I shallow /labored Chest shape (AP diameter): nonnal (AP CARDIOVASCULAR Skin: Color robust pale I jaundice I cyanotic I other: ______' Temp./ moisture wann I dry cold I moist I oily Turgor good (non-tenting) poor (tenting) Integrity intact broken I wound (location): ______Fingernails & Toenails: nonnal yellow I thick capillary refill: nonnal (<3 sec.) delayed @ __ sec. Pulses: Apical strong weak I unable to auscultate Radial strong I equal weak I unequal/ absent on R L side Pedal strong I equal weak I unequal/ absent on R L side Heart: Rhythm regular irregular Quality strong weak IV I Heplock: N/A or present Solution: -----:--Rate: ____ Site: ____ Appearance: _____ Central line I PICC line: N/ A or present 1§ge: ____ Appearance: _____ GASTROINTESTINAL Abdomen: size I shape round I fiat protuberant (obese) I scaphoid (very thin) bowel sounds present x 4/ borborygmi hypoactive I hyperactive I absent I (location): _____ Appetite: good poor I nausea I emesis (color): ______Nasogastric tube (NG): none R L nares I drainage color: _____ Fluid intake: good poor I fiuid nestriction @ __ mls/ hr Bowel movement yes no I LBM (date): -,---- BM characteristics: soft I medium brown liquid I hard (pellets) I small/ copious I blood I green I pain GENITOURINARY Urine: color I clarity yellow I clear dk. amber I bloody I cloudy I burning I incontinent catheter none foley I condom I in & out Fluid Output good poor I type & amount: ,---,------ Discharge: none vagina I penis (description): -----"----- MUSCULOSKELETAL Muscle: tone good poor Muscle strength: hand grips strong I equal weak I unequal I absent: ______foot pushes strong I equal weak I unequal/ absent: ______Joints: normal enlarged I painful . • Range of Motion (ROM): full limited /location: ___'.c.!··_· ______Gait: steady unsteady CMS (If in cast I sling I traction): good poor I limited /location: ______Amputations: no yes (location): ______ PSYCHOSOCIAL Behavior: cooperative I pleasant uncooperative I withdra\tn I combative I other: _____ Family: present absent I waiting Restraint: wrist I ankle N/A released (times): ------ skin problem no yes (describe): ------ Comments (OK to list anything here that was unique or different than any of the above choices) -Also a place to do a narrative charting on any procedure or finding - Time: ______Signature I title: ______Initial: __ © jrichards, 1997, rev. 8/2012 186 Intake and Output: Charting . Skill of the Week Objectives & Activities . • Be able to convert ounces to ml's and determine how many ml's are in the following: a six ounce coffee cup, a four ounce juice glass, a six ounce soup bowl, a eight ounce glass • Be able to use a graduate measuring device to measure a quantity of liquid (output) • Successfully perform the recording of intake and output on a standard 1&0 sheet Measuring and recording all liquid intake and output during a 24-hour period provides assessment data for fluid, electrolyte, and acid-base balance. Intake Output • Oral-all liquids taken by mouth, on tray, • Urine, voided-emptied from a bedpan, foods that are liquid at room hat, or urinal or catheter-emptied hourly temperature, soup, gelatin, ice cream, or q 8 hours juice, water in pitcher, liquid • Diarrhea medications (Maalox, Metamucil, etc.) • Vomitus • Via NG or gastrostomy tube • Gastric suction • Parenterally-IV fluids, blood or blood • Drainage from post surgical tubes products (drains) • Types of irrigation-liquid instilled into • Drainage from dressings-large the body with corresponding output amounts drainage recorded in the output • Diaphoresis-in the case of fever, extreme heat • Respiratory Routinely measured for clients after surgery, who are unstable, have a fever, are on fluid restriction, are receiving fluids by IV therapy, or are on diuretics. Especially heart and kidney patients. No doctor's order is needed. Requires help from the client and family. Nurse explains reason for measurement. Client to notify nurse after voiding. Fluid Content of Selected Foods FOOD FLUID (ML) FOOD FLUID (ML) Broth (6 oz.) 180 Juice (4 oz) 120 Coffee/tea 240 Milk (carton) 240 Creamer 15 Popsicle 90 Cup, Styrofoam (6 oz) - 4 oz 120 Fruited ice 120 liquid Ice cream, sherbet 90 Soda (can) 360 Gelatin, plain 120 Soup, cream (puree) 180 Gelatin, fruited 80 Soup, chowder or split pea 90 Equivalents: 1 cup = 240 ml 1/4 cup = 60ml '12 cup = 120 ml 1 Tbsp = 15 ml 1/3 cup = 80ml 1 oz = 30ml 187 Normal Fluid Intake & Output Breakfast Measurements Intake 1500-2500 ml/24 hr (Remember! A kg gained is a liter retained.) ~~~~~[;}2:~s~,/ Output 1500-2500 ml/24 hr (Minimum urine output is ,."gz:~~~"c 30 mllhr!) 20% Insensible loss 500-1000 ml/day Breakfast= 100% Student Name: ______D,ate: ______ All videos, CO's and/or worksheets must be complete before the student may be checked off by an instructor. Additionally, the student must have the signature of another student verifying the student has successfully performed the s k•tb"1/ e ore h.tm /h er. Activity Date Instructor Intake & Output- Mosby CO/Basic/Measurements Skill Check off: Intake & ()utput · . 5 Comments Correctly measures items from set up Check off by: __----c;::---c:--:----- Evaluator Date: ______ 188 I & 0 Sheet Student Name: ______Date: ______ D ate Sta rt e d (7 AM) 12 h our ltk&OttRna e utpu ecor d Intravenous Fluid Administration Oral Intake Fluid Output Type of Fluid and Medicntion ML Time MLinBt1g Time Type Amount Time Urine Emesis Dmin B.M. Added Infused Day Shill Summary 12" !:2uTotnl 12"Total (All Columns 7 AM- 7 PM) Total 189 Catheter Care & Discontinue Skill of the Week Objectives & Activities • Demonstrate proper care for clients with indwelling foley catheters • Demonstrate safe discontinue of a foley catheter. Indwelling Foley Catheter • For accurate intake and output • For urine retention problems • For surgical patients ' • Foley catheter may stay in for a few days to a month Catheter Care • Female: retract labia and keep hand in position during cleansing • Male: retract foreskin • Assess meatus and surrounding tissue • Cleanse pubis from front to back using a new area of the cloth with each wipe • Cleanse at catheter site first and then down the length of the catheter Assessment Questions • Able to void without difficulty prior to insertion? • Prone to urinary tract infection? • Taking in fluids well enough to promote urine productions? • Able to walk to the bathroom? • Prone to skin problems? Removal • Assess client hx for urinary problems & need for specimen • Explain: • Reason for removal • Usually does not hurt during removal, but you will feel the catheter coming out • Client to take deep breaths during removal for relaxation • Client may experience a little burning & blood in urine at first void • Client to void into specified container for measuring • Inform nurse at first void & if burning does not go away • DO NOT CUT THE PORT! & STOP IF RESISTANCE FELT! • Inspect the balloon and catheter for intactness Documentation • Client tolerance of the procedure • Balloon & foley catheter size & condition (intact) • Time foley removed & amount on 1&0 • Post first void document: Time, color, amount 190 Procedure Checklist Removing an Indwelling Catheter Check ( .Y ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, and body mechanics. Note: If patient can do self-care, instructs patient in the following steps. If not, performs them for patient. 1. Dons clean procedure gloves. 2. Instructs patient to assume a supine position. 3. Places the catheter receptacle near patient (e.g., on the bed). 4. Places a towel or waterproof drape between patient's legs and up by the urethral meatus. 5. Obtains a sterile specimen (see Procedure 27-2B), if needed. Some agencies require a culture and sensitivity test of the urine when an indwelling catheter is removed. 6. Removes the tape securing the catheter to patient. 7. Deflates the balloon completely by inserting a syringe into the balloon valve and aspirating the fluid. Verifies that the total fluid volume has been removed by checking the balloon size written on the valve port. 8. If unable aspirate all the fluid, does not pull on the catheter. 9. Instructs patient to relax and take a few deep breaths as the nurse slowly withdraws the catheter from the urethra. 10. Wraps the catheter in the towel or drape. 11. Uses warm water and a washcloth to cleanse the perineal area. Rinses well. 12. Measures the urine and then empties it in the toilet; discards the catheter, drainage tube, and collection bag in the biohazard waste receptacle. 13. Explains to patient the need to monitor the first few voids after catheter removal. If patient toilets independently, ask him to notify the nurse when he voids and to save the urine. 14. Places a receptacle in the toilet or bedside commode if patient toilets independently. 15. Encourages patient to increase fluid intake if not contraindicated by other health conditions. 16. Removes and discards gloves; washes hands. 191 Procedure Steps Yes No Comments 17. Records the date and time of the procedure; the volume, color, and clarity of the urine; and patient teaching. Recommendation: Pass, ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 192 Sterile Field, Open Gloving, Dressings & Bandages Skill of the Week Objectives & Activities .. • Be familiar with steps and rationale for open sterile gloving • State the function of sterile gloves know how to determine proper glove size • Successfully and properly perform sterile gloving • Be familiar with steps and rationales for preparing a sterile field and opening sterile packages • Successfully and properly perform setting up a sterile field and opening a sterile package • List seven purposes of dressings • List the CDC guidelines for preparing for, & changing a dressing • Maintain sterile technique during dry dressing change • Properly apply abdominal binder & elastic bandages Definition: • Medical Asepsis-absence of pathogenic organisms • Surgical Asepsis-absence of all organisms and spores Surgical Asepsis Principles • Sterile objects remain sterile only when touched by another sterile object Sterile +sterile= sterile Sterile+ contaminated= contaminated Sterile + clean = contaminated Sterile + questionable = contaminated • Only sterile objects may be placed on a sterile field • The package or container holding a sterile object must be intact and dry • A package torn, punctured, wet, or open is unsterile • Sterile object or field out of the range of vision, or an object held below a person's waist is contaminated because it cannot be viewed at all times • A sterile object or field becomes contaminated by prolonged exposure to the air • Avoid activities that create air currents after a sterile object or field becomes exposed • Do not reach over a sterile field for microorganisms can fall on the sterile items • A sterile object or field becomes contaminated by capillary action when a sterile surface comes in contact with a wet contaminated surface • Spilling solution over a sterile drape contaminates the field unless the drape cannot be penetrated by moisture • Because fluid flows in the direction of gravity, a sterile object becomes contaminated if gravity causes a contaminated liquid to flow over the objects surface • Hold your hands up while drying • Edges of a sterile field or container are contaminated (1 inch border) • Poured sterile liquid: • First pour small amount & discard • Washes away any microorganisms on the bottle lip o Second pour fills a container with the desired amount of solution 193 Seven purposes of dressings: 1. Protecting a wound from microorganism contamination - acts as a barrier between wound and outside microorganism 2. Aiding hemostasis- pressure dressings prevent bleeding of wound site; make sure pressure dressing is not too tight (check distal pulse) 3. Promoting healing by absorbing drainage and debriding a wound -absorbs drainage, exudate attaches to dressing; dressings act as a wick to pull moisture away from wound; don't pull dressings off... moisten with sterile normal saline if stuck; if for debridement, expect that it will stick as that is the purpose 4. Supporting or splinting the wound site- minimizes movement of the wound; can immobilize a body part 5. Protecting the client from seeing the wound (if perceived as unpleasant physical barrier from viewing wound 6. Promoting thermal insulation to the wound surface - keeps wound from elements 7. Providing maintenance of high humidity between the wound and dressing keeps wound moist and with high humidity Identify the most common type of dressing, and its benefits: Gauze dressings: most common; do not interact with wound tissues thus causes little wound irritation; available in different textures, shapes, and forms (pads, rolls) Transparent dressing: superficial wounds such as abrasions; acts as second temporary skin Wet dressing: often ordered as "wet to dry"; cleanses infection & dead cells Non-adherent gauze dressing: Telfa; shiny, non-adherent surface that does not stick to incisions or wound openings List the CDC guidelines for preparing for & changing a dressing: • Wash your hands well before & after dressing change • Do not directly touch wound without wearing sterile gloves • Change dressings when they are wet, or if you detect signs of infection Drainage Descriptions • Sanguinous - bloody, clots (red) • Serosanguinous - clear, blood-tinged (pinkish) • Serous- clear, watery, may be slightly yellow tinged (plasma) • Purulent- (AKA pus)- yellow/greenish, thick lumpy, may be odorous Packing/Irrigation Principles • A wound may be packed with gauze primarily to protect an open wound from contamination, absorb drainage, protect from mechanical injury, fill dead space, and debride the wound • Be sure all the surface area to be debrided is covered with gauze • Do not pack wound tightly for it will impair circulation and prevent healing • If packing tunneled areas, always leave a piece of gauze visible for easy removal • If wet-to-dry, do not apply NS to remoisten -> it is intended to debride • If wet-to-dry, you may apply NS to remove it if it sticks to the wound • Wet solutions penetrating the dry cover dressing cause wicking allowing pathogens access • If absorbing drainage, fluff the gauze prior to packing 194 Procedure Checklist Applying Sterile Gloves (Open Method) Check ( .Y ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, and body mechanics. 1. Determines correct glove size. 2. Assesses glove package for intactness and expiration date. 3. Creates a clean space for opening the package. 4. Opens the outer wrapper and places the glove package on a clean, dry surface. 5. Opens the inner package so that glove cuffs are nearest to the nurse. 6. Fully opens the package flaps so they do not fold back over and contaminate the gloves. 7. Takes care to not touch anything else on the sterile field, with the nondominant hand grasping the inner surface of the glove for the dominant hand and lifting up and away from the table. 8. Slides the dominant hand into the glove, keeping the hand and fingers above the waist and away from the body. 9. Slides gloved fingers under the cuff of the glove for the nondominant hand. 10. Lifts the glove up and away from the table and away from the body. 11. Slides the nondominant hand into the glove, avoiding contact with the gloved hand. 12. Adjusts both gloves to fit the fingers and so that there is no excess at the fingertips. 13. Keep hands between shoulder and waist level. (Note: to remove gloves, refers to the procedure for removing PPE). Recommendation: Pass. ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 195 Procedure Checklist Preparing and Maintaining a Sterile Field Check ( -.J ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, and body mechanics. 1. Assesses the sterility of all packages and equipment. 2. Positions patient before setting up a sterile field. Preparing a Sterile Field with Commercial Package: 3. Places the sterile package on a clean, dry surface. 4. Opens the flaps in this order to create a sterile field: a. Opens the flap farthest from own body. b. Opens side flaps. c. Opens flap nearest body. 5. Treats as unsterile the area 1 inch from all edges of the wrapper, and any area hanging over the edge of the table. Preparing a Sterile Field with Fabric or Paper-Wrapped Package: 6. Checks and removes the chemical indicator strip. 7. Removes the outer wrapper and places the inner package on a clean, dry surface. 8. Opens the inner wrapper following the same technique described in step 4 above. Preparing a Sterile Drape: 9. Places the package on a clean, dry surface. 10. Holds the edge of the package flap down toward the table and grasps the top edge of the package and peels back. 11. Picks up the sterile drape by the corner and allows it to fall open without touching unsterile surfaces. 12. Places drape on a clean, dry surface, touching only the edge of the drape. 13. Does not fan the drape. Adding Supplies to a Sterile Field: 14. Using the nondominant hand, peels back the wrapper in which the item is wrapped, creating a sterile barrier field with the inside of the wrapper. 15. Holding the contents through the wrapper, several inches above the field, allows the supplies to drop onto the field inside the 1-inch border of the sterile field. '"u Procedure Steps Yes No Comments 16. Does not Jet arms pass over the sterile field; does not touch supplies with nonsterile hands. 17. Disposes of the wrapper and continues opening any needed supplies for the procedure. Adding Sterile Solutions to a Sterile Field 18. If the sterile field is fabric or otherwise at risk for strikethrough, uses a sterile bowl or receptacle. It may be added to the field by unwrapping as described in the preceding section. 19. Places a sterile bowl near the edge of the sterile field. 20. Checks that the sterile solution is correct and not expired. 21. Removes the cap off the solution bottle by lifting directly up. 22. If the cap will be reused, sets it upside down on a clean area. 23. Holds the bottle of solution 4-6 inches above the bowl to pour needed amount into the bowl. Other: 24. Does not leave a sterile field unattended or outside the field of vision. Recommendation: Pass ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 197 Procedure Checklist Applying and Removing Dry Dressings Check ( .Y ) Yes or No Procedure Steps Yes No Comments 1. Check MD order for Procedure 2. Wash hands 3. Gather supplies 4. Wash hands upon entering patient room 5. I.D. patient 6. Explain procedure 7. Provide privacy 8. Places patient in a comfortable position that provides easy access to wound 9. Dons clean gloves 10. Loosens the edges of the tape of the old dressing. Stabilizes the skin with one hand while pulling the tape in the opposite direction 11. Beginning at the edges of the dressing, lifts the dressing toward the center of the wound 12. Discards gloves and soiled gauze into a biohazard bag. 13. If dressing sticks, moisten it with 0.9% (normal} saline before completely removing it 14. Assess the type and amount of drainage present on the soiled dressing 15. Assess wound for size, color of tissue present, amount and type of exudate and color 16. Disposes of soiled dressing and gloves in a biohazard receptacle Applying the Dry Dressing 1. Washes hands 2. Opens sterile packages on a clean, dry surface 3. Dons sterile gloves 4. Applies a layer of dry dressings over the wound; if drainage is expected, uses an additional layer of dressings 5. Applies tape; box technique 6. Removes gloves, turning them inside out, and discards in a biohazard receptacle 7. Positions patient for comfort 198 Procedure Steps Yes No Comments 8. Raise side rails on bed; place bed in low position 9. Provide patient with call light 10. Wash hands 11. Document procedure Recommendation: Pass, ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 199 Procedure Checklist Applying and Removing Wet-to-Damp Dressings Check ( ) Yes or No Procedure Steps Yes No Comments 1. Check MD order for Procedure 2. Wash hands 3. Gather Supplies 4. Wash hands upon entering patient room 5. J.D. patient 6. Explain procedure 7. Provide for privacy 8. Places patient in a comfortable position that provides easy access to wound 9. Dons clean gloves 10. Loosens the edges of the tape of the old dressing. Stabilizes the skin with one hand while pulling the tape in the opposite direction 11. Beginning at the edges of the dressing, lifts the dressing towards the center of the wound 12. If dressing sticks, moisten it with 0.9% 9normal) saline before completely removing it 13. Continues to remove layers until the entire dressing is removed 14. Assesses the type and amount of drainage present on the soiled dressing 15. Assesses wound for size, color of tissue present, amount and type of exudate and color 16. Disposes of soiled dressing and gloves in a biohazard receptacle Applying the Wet-to-Dry Dressing 1. Washes hands 2. Establishes a sterile field, using a sterile impermeable barrier 3. Opens sterile supplies onto a sterile field. The amount of gauze used will depend on the size of the wound 4. Opens sterile containers (saline, nugauze, gauze tub, etc.) 5. Dons one sterile glove 6. Remove dry 4X4s and places onto sterile field from 4X4 gauze tub 200 Procedure Steps Yes No Comments 7. Pours a portion of saline into trash can to sterile lip of container 8. Pours saline into 4X4 gauze tub 9. Don second sterile glove 10. Uses sterile scissors and forceps to cut nugauze and places on sterile gauze in gauze tub 11. Irrigates or cleans wound (per MD order) 12. Pack nugauze into wound using sterile cotton-tipped applicator 13. Apply wet gauze onto wound bed 14. Apply dry gauze on top of wet gauze 15. Apply ABO (outer portion of dressing) 16. Applies tape; box technique 17. Removes gloves, turning them inside out, and discards in a biohazard receptacle 18. Positions patient for comfort 19. Provide patient with call light 20. Raise side rails on bed; place bed in low position 21. Wash hands 22. Document procedure Recommendation: Pass ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 201 Procedure Checklist Applying Binders Check ( ..J \ Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, and body mechanics. 1. Choose a binder of the proper size. Measures. " 2. Washes hands. Dons gloves. 3. Thoroughly cleans and dries the part to be covered. 4. Places the body part in its natural, comfortable position (e.g., with the joint slightly flexed), whenever possible. 5. Pads between skin surfaces (e.g., under the axilla) and over bony prominences. 6. Fastens from the bottom up. 7. Changes binders whenever they become soiled or wet. Applying an Abdominal Binder: 8. Measures patient for the abdominal binder. a. Places patient in supine position. b. With a disposable measuring tape, encircles the abdomen at the level of the umbilicus. Note the measurement. This is the length of the binder. c. Measures the distance from the costal margin to the top of the iliac crests. This is the width of the binder. d. Disposes of gloves and measuring tape, and washes hands. e. Based on the measurements, obtains an abdominal binder. 9. Assists patient to roll to one side. Rolls one end of the binder to the center mark. Places the rolled section of the abdominal binder underneath patient. Positions the binder appropriately between the costal margin and iliac crest. 10. Makes sure the binder does not slip upward or downward. 11. Assists patient to turn to the other side while unrolling the binder from underneath him. 202 Procedure Steps Yes No Comments 12. With the dominant hand, grasps the end of the binder on the side furthest from self, and steadily pulls toward the center of patient's abdomen. With the nondominant hand, grasps the end of binder closest to self, and pulls toward the center. Overlaps the ends of the binder so that the Velcro® enclosures meet. 13. Removes the abdominal binder every 2 hours, and assess the underlying skin and dressings. Changes wound dressings if they are soiled, or as prescribed. Recommendation: Pass. ______Needs more practice ______ Student: ______--::-_ Date: ______203 Skills Check Off Elastic Bandage Skill Check Off: Elastic Bandage 5 Comments 1. Gather appropriate equipment 2. Wash hands, ID client, provide privacy, & explain procedure 3. Assess client's skin integrity and circulation 4. Help client to comfortable, correct position 5. With roll of bandage in dominate hand, hold Demonstrate beginning of bandage at distal body part with other spiral, reverse hand. Continue transferring bandage properly as it is spiral, & figure 8 wrapped. 6. Document actions/findings/client tolerance: Complete within 5 Explain the purposes of each type of application. minutes. 7. Evaluate distal circulation after application is completed and at least twice during 8-hour period. Check off by: __--;:;;c-:;::-:-:----- Check off by: ___;::-';""'C,------Student Evaluator Date: ______Date: ______ 204 Urinary Catheters . Skill of the Week Objectives & Activities . . • Name the three types of urinary catheters • Define catheterization • List two possible complications of catheterization • Name two forms of catheter insertion • Describe the use and be able to identify the parts of a triple-lumen foley catheter • Recognize the differences between a foley catheter and a straight catheter • List the indications for catheterizations • Successfully and properly insert a urinary catheter • Correctly apply a condom catheter Skill Goal • Maintain sterility & properly insert a urinary catheter • Utilize proper technique in the application of a condom catheter Complications • Sepsis o Sterile technique critical to avoid bacteria entering tract o Organisms may move up the catheter lumen or the space between the catheter & the urethral wall o Most clients with an indwelling catheter in place for more than 4 weeks develop bacteriuria (UTI) • Trauma o Male urethra is especially vulnerable due to its length o Insertion with force can lacerate the urethral wall o Inflating the balloon while still in the urethra can rupture the urethra wall Condom Catheter • Alternative to indwelling catheter for the male client • Applied externally to the penis • Connected to leg bag during the day & drainage bag during the night • Always follow manufacturer's instructions for applying the condom • Apply secure enough to prevent leakage, yet not so tight as to constrict the blood vessels in the area • Keep the tip of the tubing 1-2 inches away from the tip of the penis to prevent irritation • Maintain free urinary drainage, no kinks, for the ammonia in the urine can excoriate the glans penis 205 Procedure Checklist Inserting an Indwelling Urinary Catheter (Female) Check ( .Y ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, and body mechanics. 1. Takes an extra pair of sterile gloves and an extra sterile catheter into the room. 2. Ensures good lighting. 3. Dons procedure gloves. 4. Works on the right side of the bed if right-handed; the left side, if left-handed. 5. Places patient dorsal recumbent position (supine). a. Asks her to flex her knees and place her feet flat on the bed. b. Instructs patient to relax her thighs and allow them to rotate externally. 6. If patient is confused or unable to follow directions, obtains help. 7. Drapes patient. Covers upper body with blanket. Folds the blanket in a diamond shape, wrapping the corners around the patient's legs and folding the upper corner down over the perineum. 8. Lifts the corner of the privacy drape to expose the perineum. 9. Washes the perineal area with soap and water. Lets it dry. At the same time, visualizes and locates the urinary meatus. 10. Folds the corner of the privacy drape down over the perineum. 11. Removes and discards gloves. 12. Washes hands. 13. Organizes the work area: a. Bedside or overbed table within nurse's reach. b. Opens the sterile catheter kit and places on the bedside table, without contaminating the inside of the wrap. c. Positions a plastic bag or other trash receptacle so that nurse does not have to reach across the sterile field (e.g., near patient's feet); or places a trash can on the floor beside the bed. 206 Procedure Steps Yes No Comments 14. Applies a sterile drape(s) and underpad. Variation: Waterproof Underpad Packed as Top Item in the Kit: a. Removes the waterproof underpad from the kit before donning sterile gloves. Does not touch other kit items with bare hands. b. Allows the drape to fall open as it is removed from the kit. Touching only the corners and shiny side, places the drape shiny side down under the patient's buttocks. c. Dons sterile gloves (from the kit). (Touching only the glove package, removes it from the sterile kit before donning the gloves.) d. Picks up the fenestrated drape; allows it to unfold without touching other objects; places the hole over the labia. Variation: Sterile Gloves Packed as Top Item in the Kit: Uses the following steps instead of steps 14 a-d: e. Removes gloves from package, being careful not to touch anything else in the package with a bare hand. f. Grasps the edges of the sterile underpad and places it shiny side down under the patient's buttocks. g. Places fenestrated drape: Picks it up, allowing it to unfold without touching any other objects. Keeps gloves sterile. h. Places the fenestrated drape so that the hold is over the penis. 15. Organizes kit supplies on the sterile field and prepares the supplies in the kit, maintaining sterility. a. Opens the antiseptic packet; pours solution over the cotton balls. (Some kits contain sterile antiseptic swabs; if so, opens the "stick" end of the packet.) b. Lays forceps near cotton balls (omits step if using swabs). c. Opens the specimen container if a specimen is to be collected. d. Removes any unneeded supplies (e.g., specimen container) from the field. e. If there is a plastic covering on the catheter, removes it. f. Now, squeezes the sterile lubricant into the kit tray. Rolls the catheter slowly in the lubricant, being sure to lubricate the first 2.5- 5 em (1 -2 in.) of the catheter. Allow the catheter tip to stay in the sterile lubricant or on the sterile field u.,nJ~ ready to use. Procedure Steps Yes No Comments g. Attaches the saline-filled syringe to the side port of the catheter. Leaves the syringe attached to the catheter. 16. Touching only the kit or inside of the wrapping, places the sterile catheter kit down onto the sterile field between patient's legs. 17.1fthe drainage bag is preconnected to the catheter, leaves the bag on the sterile field until after the catheter is inserted. 18. Places the nondominant hand on the labia, and with the thumb and forefinger, spreads patient's labia, pulling up at the same time to expose the urinary meatus. Uses firm pressure to hold this position throughout the procedure. 19. If the labia accidentally slip back over the meatus, repeats the procedure. 20. Continuing to spread the labia with the nondominant hand, holds forceps in the dominant hand and picks up a cotton ball. 21. Wipes from the clitoris to the anus, wiping in the order of: far labium majora, near labium majora, inside far labium, inside near labium, and directly down the center over the urinary meatus. Uses only one stroke and a new cotton ball for each area. Note: If the kit has only three cotton balls, cleanses only the inside far labium minora, and the inside near labium minora, and down the center of the urethral meatus. 22. With the dominant hand, holds the catheter 3- 5 em (1 - 2 in.) from the proximal end, with the remainder of the catheter coiled in the palm of the hand. 23. Asks patient to bear down as though trying to void; slowly inserts the end of the catheter into the meatus. Asks patient to take slow deep breaths until the initial discomfort has passed. 24. Continues gentle insertion of catheter until urine flows. This is about 5-7.5 em (2- 3 in.) in a woman. Then inserts the catheter another 2.5- 5 em (1 to 2 in.) 25. If resistance is felt, withdraws the catheter; does not force the catheter. 26. After urine flows, stabilizes the catheter's position in the urethra with nondominant hand; uses the dominant hand to pick up saline-filled syringe and inflate catheter balloon. 27. If patient complains of severe pain upon inflation of the balloon, the balloon is probably in the urethra. Allows the water to drain out of the balloon, and advances the catheter 2.5 em (1 in.) farther into the bladder. 28. If it is not preconnected, connects the drainage bag to the end of the catheter. ~uu Procedure Steps Yes No Comments 29. Hangs the drainage bag on the side of the bed below the level of the bladder. 30. Using hypoallergenic, medical tape or a catheter strap, secures the catheter to the thigh or the abdomen. 31. Cleanses patient's perineal area as needed, and dries. 32. Discards supplies in a biohazard receptacle. 33. Removes gloves; washes hands. 34. Returns patient to a position of comfort. Recommendation: Pass, ______Needs more practice ______ Student ______Date: ______ Instructor: ______Date: ______209 Procedure Checklist Inserting an Indwelling Urinary Catheter (Male) Check ( .Y ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, and body mechanics. 1. Takes an extra pair of sterile gloves and an extra sterile catheter into the room. 2. Selects a catheter kit that contains lubricant, if available. 3. Ensures good lighting. 4. Works on the right side of the bed if right-handed; the left side, if left-handed. 5. Places patient supine, legs straight and slightly apart. 6. If patient is confused or unable to follow directions, obtains help. 7. Drapes patient. Covers upper body with blanket; folds linens down to expose the penis. 8. Dons clean procedure gloves and washes the penis and perineal area with soap and water. 9. If using 2% Xylocaine gel for the procedure, uses a syringe and inserts it into the urethra. - 10. Removes and discards gloves. 11. Washes hands. 12. Organizes the work area: a. Bedside or overbed table within nurse's reach. b. Opens the sterile catheter kit and places on the bedside table, without contaminating the inside of the wrap. c. Positions a plastic bag or other trash receptacle so that nurse does not have to reach across the sterile field (e.g., near patient's feet); or places a trash can on the floor beside the bed. 13. Applies sterile drape(s) and underpad. Variation: Waterproof Underpad Packed as the Top Item in the Kit: a. Removes the waterproof underpad from the kit before donning sterile gloves. Does not touch other kit items with bare hands. Allows the drape to fall open as it is removed from the kit. 210 Procedure Steps Yes No Comments b. Allows the drape to fall open as it is removed from the kit. Touching only the corners and shiny side, places the drape shiny side down across top of patient's thighs. c. Dons sterile gloves (from kit). (Touching only the glove package, removes it from the sterile kit before donning the gloves.) d. Picks up the fenestrated drape; allows it to unfold without touching other objects; places the hold over the penis. Variation: Sterile Gloves Packed as Top Item in the Kit: Uses the following steps instead of steps 13 a-d: e. Removes the gloves from the package, being careful not to touch anything else in the package with a bare hand. Dons gloves. f. Grasps the edges of the sterile underpad and places it shiny side down across the top of patient's thighs. g. Places the fenestrated drape: Picks it up, allowing it to unfold without touching any other objects. Keeps gloves sterile. h. Places the fenestrated drape so that the hole is over the penis. 14. Organizes kit supplies on the sterile field and prepares the supplies in the kit, maintaining sterility. a. Opens the antiseptic packet; pours solution over the cotton balls. (Some kits contain sterile antiseptic swabs; if so, opens the "stick" end of the packet.) b. Lays forceps near cotton balls (omits step if using swabs). c. Opens the specimen container if a specimen is to be collected. d. Removes any unneeded supplies (e.g., specimen container) from the field. e. Expresses a small amount of sterile lubricant into the kit tray; lubricates the first 2.5- 5 em (1 - 2 in.) of the catheter by rolling it in the lubricant. Does not lubricate the catheter if Xylocaine gel has already been inserted into the urethra, or if lubricant will be inserted via syringe into the urethra. f. Attaches the saline-filled syringe to the side port of the catheter. Leaves the syringe attached to the catheter. 15. Touching only the kit or inside of the wrapping, places the sterile catheter kit down onto the sterile field between or on top of patient's thighs. ., .. Procedure Steps Yes No Comments 16. If the drainage bag is preconnected to the catheter, leaves the bag on the sterile field until after the catheter is inserted. 17. With the nondominant hand, reaches through the opening in the fenestrated drape and grasps the penis, taking care not to contaminate the surrounding drape. If the penis is uncircumcised, retracts foreskin to expose the meatus. 18. If the foreskin accidentally falls back over the meatus, or if the nurse drops the penis during cleansing, repeats the procedure. 19. Continuing to hold the penis with the nondominant hand, holds forceps in the dominant hand and picks up a cotton ball. 20. Beginning at the meatus, cleanses the glans in a circular motion in ever-widening circles and partially down the shaft of the penis. 21. Repeats with at least one more cotton ball. 22. Discards cotton balls or swabs as they are used; does not move them across the open, sterile kit and field. 23. Using the nondominant hand, holds the penis gently but firmly at a 90° angle to the body, exerting gentle traction. 24. Gently inserts the tip of the prefilled syringe into the urethra and instill the lubricant. (If the kit contains only a single packet of lubricant and if no other kits are available, then lubricates 12.5- 17.7 em (5 - 7 in.) of the catheter. This is not the technique of choice, however.) 25. With the dominant hand, holds the catheter 7.5 em (3 in.) from the proximal end, with the remainder of the catheter coiled in the palm of the hand. 26. Asks patient to bear down as though trying to void; slowly inserts the end of the catheter into the meatus. Instructs patient to take slow deep breaths until the initial discomfort has passed. 27. Continues gentle insertion of catheter until urine flows. This is about 17- 22.5 em (7- 9 in.) in a man. Then inserts the catheter another 2.5- 5 em (1 to 2 in.) 28. If resistance is felt, withdraws the catheter; does not force the catheter. 29. After urine flows, stabilizes the catheter's position in the urethra with nondominant hand; uses the dominant hand to pick up saline-filled syringe and inflate catheter balloon. 30. If patient complains of severe pain upon inflation of the balloon, the balloon is probably in the urethra. Allows the water to drain out of the balloon, and advances the catheter 2.5 em (1 in.) farther into the bladder. 212 Procedure Steps Yes No Comments 31.1f it is not preconnected, connects the drainage bag to the end of the catheter. 32. Hangs the drainage bag on the side of the bed below the level of the bladder. 33. Using tape or a catheter strap, secures the catheter to the thigh or the abdomen. 34. Cleanses patient's penis and perineal area as needed, and dries. Ensures that foreskin is no longer retracted. 35. Removes gloves; washes hands. 36. Returns patient to a position of comfort. 37. Discards supplies in the appropriate receptacle. Recommendation: Pass ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 213 Procedure Checklist Applying a Condom Catheter (Male) Check ( .Y ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, and body mechanics. 1. Dons clean, procedure gloves. 2. Measures the circumference of the penis using a disposable paper tape for correct catheter fit. 3. Washes hands and don clean procedure gloves. 4. Drapes patient for privacy. 5. Organizes supplies and prepares the bedside drainage bag for attachment to the condom catheter. 6. Washes hands and dons clean, procedure gloves. 7. Positions patient supine. 8. Folds down the bedcovers to expose the penis, and drape patient using the bath blanket. 9. Gently cleanses the penis with soap and water. Rinses and dries it thoroughly. If patient is uncircumcised, retracts the foreskin, cleanse the glans, and replaces the foreskin. If patient has excess hair along the shaft of the penis carefully clips it with the scissors. 10. Washes hands and changes procedure gloves. 11. Applies skin prep to the penis and allows it to dry. 12. Holds the penis in the nondominant hand. With the dominant hand, places the condom catheter at the end of the penis, and slowly unrolls it along the shaft toward patient's body. Leaves 2.5- 5 em (1 - 2 in.) between the end of the penis and the drainage tube on the catheter. 13. Secures the condom catheter in place on the penis. 14. Assesses the proximal end of the condom catheter. 15. Secures the drainage tubing to the patient's thigh using tape or a commercial leg strap (following facility protocol). 16. Covers patient. Removes gloves, and washes hands. Recommendation: Pass ______Needs more practice ______ Student: ______Date: ______ lnstructor: ______--21:-4- Date: ______Procedure Checklist Changing an Ostomy Appliance Check ( .V ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, and body mechanics. 1. Washes hands and dons clean procedure gloves. 2. Folds down the linens to expose the ostomy site; places a clean towel across patient's abdomen under the existing pouch. 3. Positions patient so that no skin folds occur along the line of the stoma. 4. If the pouch is drainable, opens it by removing the clamp and unrolling it at the bottom. 5. Empties the existing ostomy pouch into a bedpan. 6. Saves the clamp for reuse (note that some pouches cannot be drained). 7. Using a silicone-based adhesive remover with one hand, uses the other hand to gently remove the old wafer from the skin, beginning at the top and proceeding in a downward direction. 8. Places the old pouch and wafer in a plastic bag for disposal. If the pouch is nondrainable, disposes of it according to agency protocol. 9. Inspects stoma and peristomal skin. 10. Uses warm water or skin cleansing agent with a pH of 5.5 to cleanse stoma and surrounding skin. 11. Allows the area to dry. 12. Reports excess bleeding to the physician. 13. Measures the size of the stoma in one of the following ways: a. Using a standard stoma measuring guide placed over the stoma. b. Reusing a previously cut template. c. Measuring the stoma from side to side (approximating the circumference) 14. Places a clean 4 in. x 4 in. gauze pad over the stoma. 15. Removes gloves and washes hands. 215 Procedure Steps Yes No Comments 16. Traces the size of the opening obtained in Step 13 onto the paper on the back of the new wafer; cuts the opening. Wafer opening is approximately 1.5-3 em (1/16 -1/8 in.) larger than the circumference of the stoma. 17. Peels the paper off the wafer. 18. Note: Some ostomy wafers come with an outer ring of tape attached. If so, does not remove the backing on this tape until the wafer is securely positioned (steps 22- 24). 19. Dons clean procedure gloves. 20. If ostomy skin care products are to be used, applies them at this time (e.g., wipes around stoma with skin-prep, applies skin barrier powder or paste, applies extra adhesive paste). 21. Removes the gauze. Centers the wafer opening around the stoma and gently presses down. Presses hand firmly against the newly applied wafer and holds it for 30- 60 seconds. a. If using a one-piece pouch, makes sure the bag is pointed toward patient's feet. b. If using a two-piece system, places the wafer on first. When the seal is complete, attaches the bag following manufacturer's instructions. c. for an open-ended pouch, folds the end of the pouch over the clamp and closes the clamp, listening for a "click" to ensure it is secure. 22. Removes gloves and washes hands. 23. Returns patient to a comfortable position. 24. Disposes of used ostomy pouch following agency policy for biohazardous waste. Recommendation: Pass, ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 216 Clinical Guidelines for Administering Medications • Nurses who administer medications are responsible for their own actions. Question any order that you consider incorrect. • Be knowledgeable about the medications you administer. • Federal laws govern the uses of narcotics and barbiturates. Keep these medications in a locked place. • Use only medications that are in a clearly labeled container. • Return liquid medications that are cloudy or have changed color to the pharmacy. • Before administering a medication, identify the client correctly using the appropriate means of identification, e.g., identification bracelet and/or asking clients to state their names. • Do not leave medication at the bedside, with certain exceptions, e.g., nitroglycerine, cough syrup. Determine agency policy. • If a client vomits after taking an oral medication, report this to the nurse in charge. • Take special precautions when administering certain medications; for example, have another nurse check the dosages of anticoagulants, insulin, and certain IV preparations. • Most hospitals require new orders from the physician for the client's post-surgery care. • When a medication is omitted for any reason, record the fact together with the reason. • When a medication error is made, report it immediately to the nurse in charge. RIGHTS of Drug Administration • Have client say his/her name & date of birth, ./ armband each time you give a med Client • Check the order against MAR then the MAR to drug X ,__ Drug 3 • Calculate dosages correctly Dosage • Know route abbreviations: PO, IV, IVP, OU, OD, OS, l: Route etc. Time • Check MAR, know when last given, check to see if any contra indications to being given at time on MAR, such Purpose as if other meds are being given which would enhance ~ Documentation or reduce effectiveness of drug Expiration • Know why this med is being given ~ Date • On MAR, on nurses notes if PRN medication, and any VS as indicated by type of med given, also sign out on narcotic sheet if it is a narcotic • Look all meds up before giving. Use your med sheet as a work sheet which prompts you to check for certain labs, vital signs, etc. You will be asked what drug is given for, side effects, and other information. Know your meds! 217 Preparing Medications • Let your primary nurse know that you are giving medications. • Remember your Green card. You cannot pass medications unless checked off in skills lab and an average score of 90% on math exams. • Before your instructor arrives verify the drugs are in the cart/med room, that you were able to locate the orders & allergies. Be prepared to explain and correlate medications to labs and patient assessment data. Call your instructor when ready and between the 30 minutes before to 30 minutes after the scheduled hour o ../ your order against the MAR, also allergies & pertinent labs o ../ medication three times 1. ../ label against MAR when getting it out of drawer, verify expiration date 2. ../ label against MAR when preparing medication for administration 3. ../ label against MAR when putting unused items in drawer or just before administration • Never take MAR into isolation rooms (get a label from the chart for checking patient ID) • Do not rest MAR on surfaces in the patient's room, keep in your pocket after verifying ID and discussing meds with the patient. Common Nursing Actions Before Administering Example What to Check Medications Anticoagulants Check for bleeding esp. the gums, check PTIINR, Coumadin PTT, hold according to MD guidelines Lovenox Heparin Heart meds. Check electrolytes (K, BUN, Great etc.) Dig level, Digoxin AHR (at time of administration), check VS trends, Quinidine I & 0, weight Procanamide Antihypertensives Check AHR & BP-hold if sys < 90 or according to Aldomet protocol or MD order & trends, 1&0 trend, daily HCTZ weights, electrolytes Diuretics Check BP-hold if sys < 90 or according to La six protocol or MD order & trends, I & 0 trend, daily Bumex wts, K+ Antibiotics C&S, VS trends, what organism, purpose Hormone Replacement CheckAHR Levothyroxin These are guidelines only. Check with the facility policy, MD orders, and drug book for variances. Remember, there will be more as time goes on. 218 Allergies: :Nl(CD.Jl 1 Date: 9/12/XX Time: 1000 If Generic Equivalent not acceptable check here 0 ~~ll\~~.m~ .Jlamit to '.Mercecf Co[{ege Jfospita[ 0 ~Diagnosis: CJfP, .Jlrt/iritis, qastric V{cer, CDia6etes -.... !: Q) 1. (BCR_,P cassistance .... ·-(il 2. qet permit for angiogram a. 3. t socfium cfiet :>. 4. La6s: Vj.Jl, (JBC, Lytes 2 5. :M.ecfications: I 'l{dor 40meq po aai{y :Nitro Patcli 80mg aai{y Pevite 1 ta6 po aai{y at noon J-fyarocfi{orotliiaziae 1oo mg po 6ia (])ox:y 100 mg po aai{y Noted Procainamiae JfCI 500 mg po q6/i (12-6-12-6) M. Jones RN P.mpco 30 1 ta6 po q4/i prn for pain 9-12-XX !V.JV Physician Signature: CDr. .Jl, Smitfi Date: 9/12/.XX Time: 1200 If Generic Equivalent not acceptable check here 0 P{o:J(jn 3% so{ution 2 gtts .Jls aai{y Jfumorso{Ocumeter0.125% 1 gtt OlD @1000 aai{y :Neosporin oplitfia{mic ointment OS q4/i CR..,Iiina[[ 25% 1 gtt eacli nostri{ aai{y 1'\lorea Com6ivent 1 puffq6/i A T. "'. v v"~~ '"I"" .Jlavair 100/50 infia{ecf aai{y q-12-)()( 1220 Physician Signature: CDr. .Jl, Smitfi 219 Allergies: :N'J((])Jl 1 Date: 9/13/XX Time: 1200 If Generic Equivalent not acceptable check here D }l ant£(]) ointment to wauna on Ceft arm ADDRESSOORAPH appfy fi6era[fy 6ia 0 Start I'V: (])5'W 1000m[@ 42m[jmi1i ....- (])emero[ 50 mg witli 'Vistari[ 25 mg I'M q6/i prn pain !: ·-....Q) (tl .. ' 0. M. Jones RN ~ 9-13-xx 2 !3QU Physician Signature: (]Jr. }l. Smitfi Date: 9/14/::C::C Time: 0200 If Generic Equivalent not acceptable check here D Jfeparin2500 units su6q aaify@ 0700 Insufin regu[ar 7 units/JI{PJ{ 15 units su6q aaify ac Loveno::c 80 mg su6q aaify @0700 1>.1~+~..1 5. Smith RN 9-14-xx 0215 Physician Signature: (]Jr. C. Jacf&on Date: 9/15/::(::( Time: 1000 If Generic Equivalent not acceptable check here D CCeocin vagina[ cream 1 appficator fuCC aaify }lnuso[ supp per rectum 6ia p:p:f) toaay Noted M. Jones RN 9-15-xx lU.:SU Physician Signature: (]Jr. C. Jacf&on 220 My Patient ID Diagnosis Block Merced College Registered Nursing Allergic: NKDA Page 1 off_ Medication Administration Record START STOP MEDICATION 0001 TO 1200 1201 TO 2400 Kclor 20 meq/1 0 ml 9/12/xx (Potassium Chloride) 0900 dose: 40meq po daily Nitro-Patch 0.4mg/hr 9/12/xx (Nitroglycerin) ·-· > dose: 80mg daily 0900 Fe vile 9/12/xx (B complex with iron, Vit E, C) 1200 dose: 1 tab po daily Hydro 50 mg 9/12/xx (hydrochlorothiazide) 0900 2100 dose: 100 mg po bid Doxy 100 mg 9/12/xx (doxycycline monohydrate) 0900 dose: 100 mg po daily Procana 500 mg 9/12/xx (procainamide HCI) 0600 1200 1800 2400 dose: 500mg po q 6hr Floxin 3% 9/12/xx (ofloxacin) dose: 2 gtt AS daily 1000 Humorsol Ocumeter 0.125% 9/12/xx (demecarium bromide ophthalmic) dose: 2 gtt OD daily 1000 Neosporin 3.5g 0200 1400 9/12/xx (Neosporin ophthalmic ointment) 0600 1800 dose: daily OS q4h 1000 2200 Combivent 9/12/xx (ipratropium bromide I albuterol sulfate) 0300 1100 1300 2100 dose: 1 puff Q6° PPD skin test 9/15/xx (Purified Protein Derivative) Dose: 0.1 milD (today) INITIALS NAME & PROFESSIONAL DESIGNATION INITIALS NAME 8o PROFESSIONAL DESIGNATION INITIALS NAME & PROFESSIONAL DESIQNATION 221 My Patient ID Diagnosis Block Merced College Registered Nursing Allergic: NKDA Page.£ of.£ Medication Administration Record START STOP MEDICATION 0001 TO 1200 1201 TO 2400 Advair Diskus 100/50 9/12/xx (fluticasone propionate I salmeterol) 1100 dose: inhaled daily Rhinall25% 9/12/xx (Phenylephrine Hydrochloride) 1100 dose: 2 gtts each nostril A&D ointment 9/13/xx (Vitamin A & D) 0900 2100 dose: Apply liberally to left arm wound bid Heparin 10,000 units/ml 0700 9/14/xx (Heparin Sodium Injection) dose: 2500 units subcutaneous daily Lovenox 80 mg/0.8 ml 9/14/xx (Enoxaparin Sodium) 0700 dose: 80mg subcutaneous daily Regular Insulin 100 units/ml/ NPH 100 units/ml 0700 9/14/xx (Humulin R/Humulin N) dose: Regular 7 units I NPH 15 units subcutaneous Cleocin vaginal cream 2% 9/15/xx (clindamycin phosphate) 1000 dose: 1 applicator full daily Anusol suppository 1% 9/15/xx (hydrocortisone) 1000 2200 dose: 1 rectally bid Empco 30 9/12/xx (aspirin/codeine 30 mg) Dose: 1 tab po q4hr prn pain Demerol 50 mg 9/13/xx (meperidine) Dose: 50 mg give with Vistaril lm q6h prn Vistaril 50 mg 9/13/xx (hydroxyzine) Dose: 25 mg give with DemeroiiM q6h prn INITIALS NAME !!o PROFESSIONAL DESIGNATION INITIALS NAME 1!o PROFESSIONAL DESIGNATION INITIALS NAME & PROFESSIONAL DESIGNATION 222 Oral & Topical Medication . Skill of the Week Objectives & Activities . ·· ... • Identify the nurses legal responsibility in drug administration • Correctly calculate drug dosages as supplied by instructors • Utilize the 'rights' of drug administration - lab and clinical setting • List the advantages and disadvantages of the oral route of medication administration (stat, now, routine, prn) • Utilize the rights of drug administration for topical medications • List the advantaQes and disadvantaQes of topical medications. Note: Less than 90% average math exams and you will not be able to give medication until your next math exam average is greater than or equal to 90%. PO Medication Preparation: • Check for fluid restriction, etc. • Wash hands after handling chart, etc. BEFORE pouring meds. • Do not touch medications with your bare hands. Wear gloves. • Have meds sorted in a small cup in drawer before instructor arrives (your first check don't forget expiration dates). If a narcotic, wait to sign out of drawer until instructor there, but get narcotic keys from charge nurse or med nurse. • If liquid-pour away from label. (Called palming the label) • If must cut pills, check to be sure scored, have pill cutter available. • Put somewhere on your med sheet what color pills are, etc-so if patients asks "what does this blue pill do?" you can answer correctly. • Don't turn your back on medications. If you need to get water, etc. for patient, take the pill cup with you. • Stay until all meds swallowed, return in 30 minutes to evaluate patient. Topical Medication Preparation: • Prepare lotions, creams, pastes, ointments before entering room by placing small amount in cup for application in room. Use measuring guide for nitroglycerin ointment. • Always wear gloves to apply. • Lotion- contains an insoluble powder suspended in water or an emulsion. When applied it leaves a uniform layer of powder in a film on the patient's skin. Use cotton balls or 2x2 to apply. • Cream - is an oil-in-water emulsion in a semisolid form. It lubricates the skin and acts as a barrier. Use cotton balls or 2x2 to apply. • Ointment- is a semisolid substance that when applied to the skin, helps to retain body heat and provides prolonged contact between the skin and the drug. Use tongue blade, cotton tipped swab or gloved hand to apply. • Paste- is a stiff mixture of powder and ointment. It provides a uniform coat to reduce and repel moisture. Use tongue blade, cotton tipped swab, gloved hand or application paper to apply. 223 Patient Teaching for Topical Drugs 1. Instruct patient to wash hands before and after applying the topical medication. 2. Teach how to apply the medication. 3. Be sure to stress that skin should be clean and dry before applying medication. 4. Instruct to apply only to affected area. 5. Teach how to avoid contaminating the lid or cap of the container. 6. Instruct patient to stop using the medication and to call M.D. if develops a skin irritation, ulcers, signs and symptoms of infection or a worsening skin reaction. 7. Provide written instructions. Transdermal Drug Types • Nitroglycerin to control angina • Scopolamine to treat motion sickness • Estrogen to provide hormone replacement after menopause • Clonidine to treat hypertension • Fentanyl to control chronic pain • The appropriate form ointment or patch depends largely on the desired deliver time - a patch usually delivers the drug for a longer period of time. Patient Teaching for Transdermal drugs 1. Review drug specific precautions the patient needs to know and adverse side effects to watch for. Review when to notify the doctor. 2. Make sure patient knows how to choose an appropriate site for application of drug. 3. Instruct patient not to get any Transdermal ointment on his hands and to wash before and after applying drug. 4. Keep area around patch as dry as possible. 5. Provide written instructions. 224 Procedure Checklist Medication Guidelines: Steps to Follow for All Medications, Regardless of Type or Route Check ( .Y ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, and body mechanics, and documentation. 1. First Check checks medication order on MAR against physicians' prescription (patient name, patient identifier, mediation, dose, route, time, and allergies.) 2. Follows agency policies for medication administration, including the time frame for medication administration. Most agencies allow medications to be given 30 minutes before or 30 minutes after the time indicated in the MAR. 3. Knows drug information, including drug action, purpose, recommended dosage, time of onset and peak action, common side effects, contraindications, drug interactions, nursing implications. 4. Determines if medication dosage is appropriate for patient's age and weight. 5. Identifies any special considerations for medication preparation and administration, such as whether medication should be administered with food or on an empty stomach. 6. Checks expiration date of medication. 7. Second Check: When preparing medication, verifies correct medication, dose, time, route, and expiration date. Checks for patient drug allergies. 8. Calculates dosage accurately. 9. Locks medication cart after removing medication. 10. Identifies patient by two methods, following agency policy. 11. Third Check: At the bedside, verifies correct patient (using two methods of identification, including armband), medication, expiration date, dose, route, time and presence of drug allergies. 12. Performs any assessments that are related to the medication to be given, such as checking the pulse or blood pressure. 13. Remains with the patient until sure he has taken the medication. 14. Does not leave medication unattended at bedside. 225 Procedure Steps Yes No Comments 15. Reassesses for therapeutic and side effects. 16. Teaches patient about the medication as needed. 17. Documents the medication given in the patient medication record. Recommendation: Pass. ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 226 Procedure Checklist Administering Oral Medications Check ( -.J ) Yes or No Procedure Steps Yes No Comments 1. Check MD order- Checks the medication order against the Medication Administration Record (MAR); patient name, patient birthdate, medication, dose, route, time & allergies 2. Follows agency policy for medication administration including the time frame for medication administration (most agencies allow medications to be given 30 minutes before or 30 minutes after the time indicated in the MAR). 3. Knows drug information, including drug action, purpose, recommended dosage, time of onset and peak action, common side effects, contraindications, drug interactions, nursing implications 4. Determines if medication dosage is appropriate for patient's age and weight 5. Identifies any special considerations for medication preparation and administration 6. Attains medication from medication cart/computer 7. First Check: Checks medication against MAR (medication, dose, time, route and expiration date) B. Second Check: Checks medication against MAR (medication, dose, time, route and expiration date) 9. Calculates dosage accurately 10. Washes hands upon entering patient's room 11. Identifies patient by two methods 12. Provides for privacy 13. Explains procedure 14. Third Check: At bedside, verifies medication, expiration date, dose, route, time and presence of drug allergies 15. Opens medication and places in medication cup without touching medication (if liquids, shake medication and pour into cup from the side of the container away from the label) 16. If sublingual, administer under tongue. If buccal, administer between cheek and teeth 17. Performs any assessments that are related to the medication to be given, such as checking the pulse and blood pressure 18. Remains with the patient until sure patient has taken the medication 19. Does not leave medication unattended at bedside 227 Procedure Steps Yes No Comments 20. Reassesses for therapeutic and side effects 21. Teaches patient about the medication 22. Washes hands 23. Documents the medication given in the patients record Recommendation: Pass, ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 228 Procedure Checklist Administering Topical Medications Check (-.,; ) Yes or No Procedure Steps Yes No Comments 1. Check MD order- Checks the medication order against the Medication Administration Record (MAR); patient name, patient birthdate, medication, dose, route, time & allergies 2. Follows agency policy for medication administration, including the time frame for medication administration (most agencies allow medications to be given 30 minutes before or 30 minutes after the time indicated in the MAR) 3. Knows drug information, including drug action, purpose, recommended dosage, time of onset and peak action, common side effects, contraindications, drug interactions, nursing implications 4. Determines if medication dosage is appropriate for patient's age and weight 5. Identifies any special considerations for medication preparation and administration including supplies needed 6. Attains medication from medication cart/computer/cabinet 7. First Check: Checks medication against MAR (medication, dose, time, route and expiration date) 8. Second Check: Checks medication against MAR (medication, dose, time, route and expiration date) 9. Washes hands upon entering patient's room 10. Identifies patient by two methods 11. Provides for privacy 12. Explains procedure 13. Third Check: At bedside, verifies medication, expiration date, dose, route, time and presence of drug allergies 14. Don clean gloves 15. Cleanses the skin with soap and water and pats dry before applying to enhance absorption 16. Opens medication and uses gloves or an applicator to apply and spread the medication evenly, following the direction of hair growth when coating the area 17. When treating skin disease or skin wound infections, rub medication into the skin until the medication is no longer visible Powders 18. Spreads apart skinfolds, and applies a very thin layer 229 Procedure Steps Yes No Comments 19. Applies the powder to clean, dry skin. Is careful that patient does not inhale powder Transdermal Medication 20. Removes previous patch, folding the medicated side to the inside 21. Disposes of the old patch carefully in an appropriate receptacle 22. Cleanses skin area of traces of remaining medication. Allows skin to dry 23. Removes patch from packaging 24. Write date and time on the patch 25. Applies patch to skin (application sites must be rotated) 26. Avoid skin areas with lesions and hair 27. Teaches patient not to use heating pads over the patch 28. Removes gloves All Topicals 29. Reassesses for therapeutic and side effects 30. Teaches patient about the medication 31. Bed in low position, side rails up, provide patient with call light 32. Removes gloves and washes hands 33. Documents the medication given in the patients record Recommendation: Pass. ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 230 Administration of Injections (Subcutaneous Intradermal & Intramuscular) •. Skill oftlle Week Objectives & Activities . • Correctly calculate prescribed drug dosages. • Describe factors to consider when choosing routes for parenteral drug administration. • Correctly prepare and administer subcutaneous, intradermal and intramuscular injections. • Correctly mix medications a) Tubex & ampule b) Tubex & vial c) Tubex & tubex d) Reconstitution of medications • Correctly identify all landmarks for subcutaneous, intradermal & intramuscular injections. Insulin Injections • Identify safe locations for administration of subcutaneous insulin injections. • Verify dose with another RN who must sign the MAR • Verbally explain relationship of pertinent labs and point of care testing. Heparin & Lovenox Injections • Correctly calculate prescribed dosage of heparin and/or Loven ox • Verify dose with another RN who must sign the MAR • Describe factors to consider when administering parenterally • Identify safe locations for administration of heparin • Correctly prepare and administer heparin • Verbally explain relationship of pertinent labs Syringe Safety • Use syringes with safety features • Plan safe handling and disposal before An estimated 800,000 beginning any procedure using needles needlestick iitiuries • Avoid recapping needles & then only if the occur among healtl1 care needle has not been used workers mmually • Dispose of used syringes promptly in To protect yourself and appropriate sharps disposal containers coworkers, be aware of • Report all sharp related injuries promptly to tl1e hazards posed by your supervisor needlestick injuries Insulin Syringes U-100 insulins are measured using U-100 calibrated syringes. The smallest capacity syringe possible is used for ease & accuracy. 231 Premixed lnsulins Humulin 70/30 & Novolin 70/30 Novo log Mix 70/30: 70% as part protamine/ 30% aspart Humalog Mix 75/25: 75% lispro protamine/25% Jispro Never mix these with other insulin products. Do not give IV! Onset/Peak/Duration Insulin Onset Peak Duration Rapid Acting (Lispro; Aspart) 15 min 1 hour 2-4 hours Short Acting (Regular) 30 min 2-4 hours 6-8 hours Intermediate Acting (NPH; Lente) 1 -4 hours 6-12 hours 18-28 hours Long Acting (Giargine; Ultralente) 1-8 hours NONE 24-36 hours Combinations (Regular+) 30 min 4-8 hours 24 hours For Regular insulin think "Cheer" 2, 4, 6, 8: Symptoms of Hypoglycemia (Cold & Wet): Increased anxiety, blurred vision, chilly sensation, cold diaphoresis, pallor, confusion, drowsiness, headache, increased pulse rate, shakiness, increased weakness, increased appetite. Symptoms of Hyperglycemia (Hot & Dry): Drowsiness, red and dry skin, fruity breath odor, anorexia, polyuria, rapid and deep breathing, thirst, weight loss, nausea, vomiting, dry mouth. 232 Procedure Checklist Administration of a Subcutaneous Injection of Heparin Check ( .Y ) Yes or No Procedure Steps Yes No Comments 1. Check MD order- Checks the medication order against the Medication Administration Record (MAR); patient name, patient birthdate, medication, dose, route, time & allergies 2. Follows agency policy for medication administration, including the time frame for medication administration (most agencies allow medication to be given 30 minutes before or 30 minutes after the time indicated in the MAR) 3. Knows drug information, including drug action, purpose, recommended dosage, time of onset and peak action, common side effects, contraindications, drug interactions, nursing implications 4. Determines if medication dosage is appropriate for patient's age and weight 5. Identifies any special considerations for medication preparation and administration (i.e.: PTT results & signs and symptoms of excessive bleeding) 6. Selects the appropriate syringe and needle. In addition to considering the amount of adipose tissue 7. For Heparin volumes <1 ml, uses a tuberculin (TB) syringe with a 25-27 gauge, 3/8- 5/8 inch needle 8. Attains medication from medication cart/computer 9. First Check: Checks medication against MAR (medication, dose, time, route and expiration date) 10. Second Check: Checks medication against MAR (medication, dose, time, route and expiration date) 11. Washes hands upon entering patient's room 12. Identifies patient by two methods 13. Provides for privacy 14. Explains procedure 15. Teaches patient about the Heparin including signs and symptoms of excessive bleeding 16. Asks patient about allergies 17. Takes cap off needle. Holds cap in hand or places cap on clean surface away from opening 18. Cleans top of vial with alcohol wipe 19. Draws up air in syringe (same amount as prescribed Heparin dose) 233 Procedure Steps Yes No Comments 20. Injects air in Heparin vial 21. Inverts syringe and draws up prescribed Heparin dose in syringe 22. Double checks heparin dose with 2"d licensed nurse 23. Removes needle from Heparin vial 24. Recaps needle with the scope-method (the only time that the needle is recapped) 25. Third Check: At bedside, verifies medication, expiration date, dose, route, time and presence of drug 26. Dons procedure gloves 27. Selects appropriate site for Heparin administration 28. Opens alcohol wipe and 2x2 packages 29. Cleans injection site with alcohol wipe 30. Allows alcohol to dry 31. Holding the syringe between thumb and index finger of the dominant hand like a pencil or dart, inserts needle at a 45- 90° angle; depending on the amount of adipose tissue. May also "pinch" adipose tissue depending on the amount of adipose tissue 32. Stabilizes the syringe with the fingers of the nondominant hand 33. Removes needle along the line of the insertion. Does not recap needle 34. Engages the needle safety device or places uncapped syringe and needle directly in the sharps container 35. Applies 2x2 over injection site. Does Not Massage Site 36. Reassesses for therapeutic and side effects 37. Places bed in low position 38. Makes sure side rails are up on bed 39. Makes patient comfortable 40. Washes hands 41. Documents the medication given in the patients record 234 Lovenox Subcutaneous Injection (Differences from Heparin Injection) 1. Identifies that Lovenox is packaged in a pre-filled syringe 2. Does not remove air from syringe 3. For dosage adjustments, syringe must be held with the needle pointing downward 4. Correct site selection (Anterolateral, Posterolateral and lateral abdomen) "love handles" Recommendation: Pass. ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 235 Heparin/Lovenox Administration Sodium Heparin Injection, USP / Used to interrupt the clotting process. / May be given in therapeutic doses or in small diluted doses to maintain the patency of IV or arterial lines. / Is usually administered deep subcutaneous or IV. Never give IM, causes hematoma and pain, or never given orally as it is inactive. / Orders are individualized and based on lab studies. Heparin comes in various strengths, including 5000, 10,000, 20,000 and 50,000 Units/ml. Heparin also comes in 10 and 100 Units/ml as intravenous patency flushes. / When multidose vials are available, choose the strength that will ensure that less than 1 ml will be injected subcutaneous. Have a registered nurse check the order, dose, vial, and amount before administering. The second nurse initials the MAR as well as a witness. / Heparin is fast acting and counteracted with protamine sulfate. Check lab values for clotting times before administering heparin. APTT (Activated Partial Thromboplastin Time) *usually done in Merced Normal 25 - 38 seconds (FDA) Therapeutic range 1 1fz to 2 1fz times normal = 37.5- 95 seconds Preferred therapeutic range is 60 - 80 seconds PTT (Partial Thromboplastin Time) Normal 60 - 90 seconds (FDA) Therapeutic range 1 1fz to 2 times normal = 90 - 180 seconds / Watch for symptoms of overdose including nosebleed, tarry stools, petechiae, and easy bruising. / For administration, always use TB syringe. Add 0.02 ml air to syringe to ensure all med is administered and prevent tracking. Give subcutaneous without aspirating. Enoxaparin (Lovenox) / Low molecular weight heparin used especially for prevention of Deep Vein Thrombosis (DVT) following knee replacement or hip replacement. Has fewer adverse effects than heparin. Daily coagulation studies are not needed. Assess platelet count occasionally. / Administered in a fixed dose, usually 30 mg BID within 12 to 24 hours after surgery provided hemostasis has occurred. Usually given for 7 to 10 days. Administer subcutaneously in "love handles" (costal margins & iliac crest) / No lab tests are required. 236 Lovenox (enoxaparin sodium) Injection 6. Pinch skin between thumb and index 2. To remove protective covering, pull it finger to make a skin fold. lengthwise away from the needle with a slight rotating motion. 3. Do not expel air out of syringe. 7. Insert full length of needle vertically 4. Always administer the subcutaneous into skin fold. injection when the patient is lying down. LOVENOX must not be administered by intramuscular injection. 5. The ideal site for injection is the cell mass under the skin of the anterolateral and posterolateral abdominal wall. Alternate injections between right and left anterolateral and posterolateral sides. 8. Inject LOVENOX slowly; be sure to hold the skin fold throughout the injection. 237 Procedure Checklist Administration of a Subcutaneous Injection of Mixed Insulin Check ( -.J ) Yes or No Procedure Steps Yes No Comments 1. Check MD order- Checks the medication order against the Medication Administration Record (MAR); patient name, patient birthdate, medication, dose, route, time & allergies 2. Follows agency policy for medication administration, including the time frame for medication administration (most agencies allow medication to be given 30 minutes before or 30 minutes after the time indicated in the MAR) 3. Knows drug information, including drug action, purpose, recommended dosage, time of onset and peak action, common side effects, contraindications, drug interactions, nursing implications 4. Determines if medication dosage is appropriate for patient's age and weight 5. Identifies any special considerations for medication preparation and administration 6. Selects the appropriate syringe and needle. In addition to considering the amount of adipose tissue. 7. Use an insulin syringe- typically 0.3, 0.5 or 1.0ml. Most insulin needles are 28-31 gauge. Needle length is often 3/16 -1 inch 8. Attains medication from medication cart/computer 9. First Check: Checks medication against MAR (medication, dose, time, route and expiration date) for both insulins 10. Second Check: Checks medication against MAR (medication, dose, time, route and expiration date) for both insulins 11. Washes hands upon entering patient's room 12. Identifies patient by two methods 13. Provides for privacy 14. Explains procedure 15. Teaches patient about the medication including signs and symptoms of hypoglycemia 16. Asks patient about allergies 17. Rolls NPH (cloudy) insulin vial in hands 18. Takes cap off needle. Holds cap in hand or places cap on clean surface away from opening 19. Cleans tops of both vials with alcohol wipe 238 Procedure Steps Yes No Comments 20. Draws up air in syringe for the same amount of NPH insulin 21. Injects air in NPH Insulin vial 22. Draws up air in syringe for the same amount of Regular insulin 23. Injects air into Regular insulin vial 24. Inverts Regular Insulin vial and draws up the prescribed amount of Regular insulin 25. Double checks Regular insulin dose with 2"' licensed nurse 26. Removes needle from Regular insulin vial 27. Inserts needle into NPH insulin syringe 28. Draws up the prescribed amount of NPH insulin; being careful to draw up the correct dose with going over 29. Double checks combined insulin dose with 2"' licensed nurse 30. Removes needle from NPH insulin vial 31. Recaps needle with the scope-method (the only time that the needle is recapped) 32. Third Check: At bedside, verifies medication, expiration date, dose, route, time and presence of drug allergies (for both insulins) 33. Dons procedure gloves 34. Selects appropriate site for insulin administration 35. Opens alcohol wipe and 2x2 packages 36. Cleans injection site with alcohol wipe 37. Allows alcohol to dry 38. Holding the syringe between thumb and index finger of the dominant hand like a pencil or dart, inserts needle at a 45- 90° angle; depending on the amount of adipose tissue 39. Stabilizes the syringe with the fingers of the nondominant hand 40. Using the thumb of the dominant hand, presses the plunger slowly injecting the medication 41. Removes needle smoothly along the line of insertion. Does not recap needle 42. Engages the needle safety device or places uncapped syringe directly in the sharps container 43. Applies 2x2 over injection site. Does not massage injection site 239 Procedure Steps Yes No Comments 44. Disposes of sharps safely 45. Reassesses for therapeutic and side effects 46. Places bed in low position 47. Makes sure side rails are up on bed 48. Makes patient comfortable 49. Washes hands 50. Documents the medication given in the patients record Recommendation: Pass ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 240 Procedure Checklist Administration of Intradermal Injections Check (--/ ) Yes or No Procedure Steps Yes No Comments 1. Check MD order- Checks the medication order against the Medication Administration Record (MAR); patient name, patient birthdate, medication, dose, route, time & allergies 2. Follows agency policy for medication administration 3. Knows drug information, including drug action, purpose, recommended dosage, time of onset and peak action, common side effects, contraindications, drug interactions, nursing implications 4. Selects the appropriate syringe and needle. Uses a tuberculin (TB) syringe with a 25-27 gauge, 3/8- 5/8 inch needle 5. Attains medication from medication cart/computer 6. First Check: Checks medication against MAR (medication, dose, time, route and expiration date) 7. Second Check: Checks medication against MAR (medication, dose, time, route and expiration date) 8. Washes hands upon entering patient's room 9. Identifies patient by two methods 10. Provides for privacy 11. Explains procedure 12. Teaches patient about Purified Protein Derivative (PPD) and the expectations of the test 13. Asks patient about allergies 14. Takes cap off needle. Holds cap in hand or places cap on clean surface away from opening 15. Cleans top of vial with alcohol wipe 16. Draws up air in syringe (same amount as prescribed medication dose) 17. Injects air into vial 18. Inverts syringe and draws up prescribed medication dose in syringe 19. Removes needle from vial 20. Recaps needle with the scope-method (the only time that the needle is recapped) 21. Third Check: At bedside, verifies medication, expiration date, dose, route, time and presence of drug 241 Procedure Steps Yes No Comments 22. Dons procedure gloves 23. Selects and correctly locates the site for injection. Usual sites are the ventral surface of the forearm and upper back. The upper chest may also be used 24. Assists patient to a comfortable position. If using a forearm, instructs patient to extend and supinate arm on a flat surface. If using the upper back, instructs patient to a prone position or a prone position or to Jean forward over a table or the back of a chair 25. Opens alcohol wipe and 2x2 packages 26. Cleans injection site with alcohol wipe 27. Allows alcohol to dry 28. Holds syringe between the thumb and index finger of the dominant hand parallel to skin 29. With the non-dominant hand, holds skin taut by on the following methods: a. If using a forearm, may be able to place a hand under the arm and pull the skin tight with thumb and fingers b. Stretching skin between thumb and finger c. Pulling the skin toward the wrist or down with one finger 30. While holding the skin taut with the non-dominant hand, holds syringe in the dominant hand with the bevel up and parallel to patient's skin at a 5° to 15° angle 31. Inserts needle slowly and advances approximately 3mm (1/8 inch) so that the entire bevel is covered. The bevel should be visible under the skin 32. Releases the taut skin and holds the syringe stable with non- dominant hand. Does not aspirate 33. Slowly injects the solution. A pale wheal, about 6-10mm (1/4 inch) in diameter should appear over the needle bevel 34. Removes the needle 35. Engages the needle safety device or places uncapped syringe and needle directly in the sharps container 36. Gently blots any blood with 2x2. Does not rub or cover with an adhesive bandage 37. With a pen, draws a 1 inch circle around the bleb/wheal 38. Places bed in low position 39. Makes sure side rails are up on bed 40. Makes patient comfortable 242 Procedure Steps Yes No Comments 41. Washes hands 42. Documents the medication given in the patients record Recommendation: Pass. ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 243 Procedure Checklist Administration of Intramuscular Injections Check ( ;J ) Yes or No Procedure Steps Yes No Comments 1. Check MD order- Checks the medication order against the Medication Administration Record (MAR); patient name, patient birthdate, medication, dose, route, time & allergies 2. Follows agency policy for medication administration, including the time frame for medication administration (most agencies allow medications to be given 30 minutes before or 30 minutes after the time indicated in the MAR) 3. Knows drug information, including drug action, purpose, recommended dosage, time of onset and peak action, common side effects, contraindications, drug interactions, nursing implications 4. Determines if medication dosage is appropriate for patient's age and weight 5. Identifies any special considerations for medication preparation and administration 6. Selects the appropriate syringe and needle, considering volume and type of medication and patient's muscle mass a. Usual syringe 1 - 3m I b. Usual needle is 21-25 gauge, 1-3 inch length for adults 7. Attains medication from medication cart/computer 8. First Check: Checks medication against MAR (medication, dose, time, route and expiration date) 9. Second Check: Checks medication against MAR (medication, dose, time, route and expiration date) 10. Washes hands upon entering patient's room 11. Identifies patient by two methods 12. Provides for privacy 13. Explains procedure 14. Teaches patient about the medication 15. Asks patient about allergies 16. Takes cap off needle. Holds cap in hand or places cap on clean surface away from opening 17. Cleans top of vial with alcohol wipe 18. Draws up air in syringe for the same amount of prescribed medication 244 Procedure Steps Yes No Comments 19. Injects air into vial 20. Inverts vial and draws up medication into syringe 21. Removes needle from vial 22. Recaps needle with the scope-method (the only time that the needle is recapped) 23. Third Check: At bedside, verifies medication, expiration date, dose, route, time and presence of drug allergies 24. Dons procedure gloves 25. Opens alcohol wipe and 2x2 packages 26. Selects appropriate site for intramuscular injection (Rotate sites) Deltoid Site: a. Uses this site for small amounts of medication, immunizations, or when the ventrogluteal or vastus lateral is site are contraindicated b. Completely exposes patient's upper arm, removing the garment if necessary c. Locates the lower edge of the acromion process and goes 2 - 3 fingerbreadths down d. Draws an imaginary line out from the axillary crease. The resulting inverted triangle is the deltoid site e. AI alternative approach is to place four fingerbreadths across the deltoid muscle with the top finger on the acromion process 27. Rectus Femoris: Divides the top of the thigh from the groin to the knee into thirds and identifies the middle third. Visualizes a rectangle in the middle of the anterior surface of the thigh. This location of the injection site 28. Vastus Lateralis: a. Instructs patient to assume a supine or sitting position b. Locates the greater trochanter and the lateral femoral condyle c. Places hands on patient's thigh with one hand against the greater trochanter and the edge of the other hand against the lateral femoral condyle 245 Procedure Steps Yes No Comments d. Visualizes a rectangle between the hands across the anterolateral thigh. The index fingers of the hands form the smaller ends of the rectangle. The long sides of the rectangle are formed by (a) drawing an imaginary line down the center of the anterior thigh and (b) drawing another line along the side of the leg, halfway between the bed and the front of the thigh. This box marks the middle third of the anterolateral thigh, which is the injection site 29. Ventrogluteal Site: a. Instructs patient to assume a side-lying position, if possible b. Locates the greater trochanter, anterior superior iliac spine, and the iliac crest c. Places the palm of the hand on the greater trochanter, index finger on the anterior superior iliac spine, and the middle finger pointing toward the iliac crest (uses the right hand on patient's left hip; uses the left hand on the patient's right hip) d. The middle of the triangle between the middle and index fingers is the injection site 30. Dorsogluteal Site: a. Divide the buttocks into four imaginary quadrants b. Palpate the posterior iliac spine and the greater trochanter c. Draw an imaginary diagonal line between the two marks d. Injection site is superiorly and laterally to the midpoint of the diagonal line e. Keep in mind, this site is less preferred because of the possibility of improperly identifying the site; which can cause damage to the sciatic nerve thereby causing paralysis 31. Palpates the landmarks and the muscle mass to ensure correct location and muscle adequacy 32. Cleans injection site with alcohol wipe 33. Allows alcohol to dry 34. With the nondominant hand, holds the skin taut between the thumb and index finger Alternative Method (Z-Track Method): With the lateral aspect of the nondominant hand, displaces the skin away from injection site about 2.5- 3.5cm (1 - 1.5 inches) 35. Holding the syringe between thumb and index finger of the dominant hand like a pencil or dart, inserts needle at a 90° 246 Procedure Steps Yes No Comments 36. Stabilizes the syringe with the fingers of the nondominant hand 37. Aspirates by pulling back slightly on the plunger for 5-10 seconds. If a blood return is obtained, removes the needle, discards and prepares the medication 38. If there is no blood return with aspiration, using the thumb of the dominant hand, presses the plunger slowly injecting the medication (5- 10 seconds/ml) 39. Removes needle smoothly along the line of insertion. Does not recap needle 40. For Z-Track Injection Method: Waits for 10 seconds, then removes the needle smoothly along the line of the insertion; then immediately releases the skin 41. Engages the needle safety device or places uncapped syringe directly in the sharps container 42. Applies 2x2 over injection site by blotting and applying light pressure along with applying an adhesive bandage as needed 43. Disposes of sharps safely 44. Reassesses for therapeutic and side effects 45. Places bed in low position 46. Makes sure side rails are up on bed 47. Makes patient comfortable 48. Washes hands 49. Documents the medication given in the patients record Recommendation: Pass, ______Needs more practice ______ Student ______Date: ______ Instructor: ______Date: ______ 247 Procedure Checklist Locating Intramuscular Injection Sites Check ( ) Yes or No Procedure Steps Yes No Comments Before, during, and after the procedure, follows "Principles-Based Checklist to Use with All Procedures," including: Identifies the patient according to agency policy; attends appropriately to standard precautions, hand hygiene, safety, privacy, and body mechanics, and documentation. 1. Palpates the landmarks and the muscle mass to ensure correct location and muscle adequacy. Deltoid Site: 1. Uses this site for small amounts of medication, immunizations, or when the ventrogluteal or vastus lateralis site are contraindicated. 2. Completely exposes patient's upper arm, removing the garment if necessary. 3. Locates the lower edge of the acromion process and goes 2 - 3 fingerbreadths down. 4. Draws an imaginary line out from the axillary crease. The resulting inverted triangle is the deltoid site. 5. An alternative approach is to place four fingerbreadths across the deltoid muscle with the top finger on the acromion process. Rectus Femoris: (Not a site of choice) 1. Divides the top of the thigh from groin to the kneed into thirds and identifies the middle third. Visualizes a rectangle in the middle of the anterior surface of the thigh. This is location of the injection site. Vastus Latera/is: 1. Instructs patient to assume a supine or sitting position. 2. Locates the grater trochanter and the lateral femoral condyle. 3. Places hands on patient's thigh with one hand against the greater trochanter and the edge of the other hand against the lateral femoral condyle. 248 Procedure Steps Yes No Comments 4. Visualizes a rectangle between the hands across the anterolateral thigh. The index fingers of the hands form the smaller ends of the rectangle. The long sides of the rectangle are formed by (a) drawing an imaginary line down the center of the anterior thigh and (b) drawing another line along the side of the leg, halfway between the bed and the front of the thigh. This box marks the middle third of the anterolateral thigh, which is the injection site. Ventrog/utea/ Site: 1. Instructs patient to assume a side-lying position, if possible. 2. Locates the greater trochanter, anterior superior iliac spine, and the iliac crest. 3. Places the palm of the hand on the greater trochanter, index finger on the anterior superior iliac spine, and the middle finger pointing toward the iliac crest. (Uses the right hand on patient's left hip; uses the left hand on patient's right hip.) 4. The middle of the triangle between the middle and index fingers is the injection site. Recommendation: Pass ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 249 Illustrations oflntramuscular Injection (IM) Sites 1M injections can be administered into the muscles shown below. In these illustrations, specific injection sites are shaded. Deltoid Acromial proms Deltoid musd.e Scapula-----" Deep brocniol artery Radial neiVe ---"' Humerus ---.!! Vastus lateralis and rectus femoris Vastus lateralls ___, __,_, Ventre gluteal Iliac· c.rest----__,"": Dorsogluteal Posterior superior iliac spine Gluteus"'"'""'" 250 Injection Angles for Subcutaneous, Intramuscular, and Intradennal injections. 251 Ophthalmic, Otic, Vaginal, & Rectal Drug Administration . Skill of the Week Objectives & Activities • Utilize the rights of drug administration for optic, otic, vaginal, & rectal medications • List the advantages and disadvantages of optic, otic, vaginal & rectal medications • Identify contraindications for rectal administration. Ophthalmic Drugs Typically given for diagnostic and therapeutic purposes such as dilating the pupil, staining the cornea, anesthetizing the eye, lubricating, treating eye disorders like infections or glaucoma, and protecting the vision of neonates. Most common forms are drops or ointments. Key points • Make sure eye is free of discharge • Never use the same eye medication for more than one pt. • Many elderly have difficulty holding bottle steady • Never touch the bottle tip to the eye or any other surface Patient teaching for ophthalmic drugs 1. Instruct patient regarding the purpose of the drops or ointment, adverse side effects to watch for and when to notify the doctor. 2. Stress importance of proper hand washing before and after using eye medication. 3. Teach patient to make sure they have the right medication, the correct# of drops, and the correct eye. 4. Instruct patient that eye medication best given at room temperature. 5. If administering more than one eye medication best to wait at least 5 minutes between administrations. 6. Stress the importance of never placing any medication in the eyes unless the label reads for ophthalmic use or for use in eyes. 7. Provide written instructions. Otic Drugs • Treat inflammation and infection • Produce local anesthesia • Soften ear wax • Aid in foreign body removal Key points • Never insert anything into the ear so far that you can't see the tip • Pull pinna down & back for children and up & outward for adults • Have drug at room temp to avoid vertigo, dizziness, nausea Patient teaching for otic drugs 1. Tell patient to never to insert any object into the ear. 2. Review importance of hand washing. 3. Review with patient how many drops and into which ear. 4. Review purpose of medication, adverse side effects to look for and when to notify doctor. 5. Teach patient not to use medication if it looks discolored or contains sediment and to call doctor or pharmacist. 6. Provide written instructions. 252 Vaginal Medication Uses • Inflammation • Infections • Discomfort • Contraceptive use Forms of Vaginal Medications Creams, Gels, Ointments Inserted with a tubular applicator, gloves, & water soluble lubricant Foams Placed on a diaphragm & inserted Douches Requires an irrigation bag Suppositories Inserted with a gloved hand & water soluble lubricant Client Education • Post application: - Explain to client that she may experience some drainage & may need to use a pad or liner -Caution not to use tampons as they may absorb the medication thereby reducing the effectiveness Rectal Medication Uses • Treat local conditions: Pain, inflammation, itching • May also be used in the treatment of: Fever, Nausea, Constipation Forms of Rectal Medications Enema Water, container, gloves & water soluble lubricant Suppository yVater soluble lubricant, gloves & tissue Ointment Water soluble lubricant, gloves, & gauze pad Contraindications for Rectal Suppositories • In cardiac clients may stimulate the vagus nerve causing a vagal response & cardiac dysrhythmias May cause trauma in clients following rectal surgery 253 Procedure Checklist Administering Vaginal Medications Check ( -.J ) Yes or No Procedure Steps Yes No Comments 1. Check MD order- Checks the medication order against the Medication Administration Record (MAR); patient name, patient birthdate, medication, dose, route, time & allergies 2. Follows agency policy for medication administration, including the time frame for medication administration (most agencies allow medications to be given 30 minutes before or 30 minutes after the time indicated in the MAR) 3. Knows drug information, including drug action, purpose, recommended dosage, time of onset and peak action, common side effects, contraindications, drug interactions, nursing implications 4. Determines if medication dosage is appropriate for patient's age and weight 5. Identifies any special considerations for medication preparation and administration 6. Attains medication from medication cart/computer 7. First Check: Checks medication against MAR (medication, dose, time, route and expiration date) 8. Second Check: Checks medication against MAR (medication, dose, time, route and expiration date) 9. Calculates dosage accurately (if needed) 10. Washes hands upon entering patients room 11. Identifies patient by two methods 12. Provides for privacy 13. Explains procedure 14. Teaches patient about the medication 15. Third Check: At bedside, verifies medication, expiration date, dose, route, time and presence of drug allergies 16. Dons gloves 17. Asks patient to void before procedure 18. Positions patient in a dorsal recumbent or Sims position 19. Drapes patient with a bath blanket so that only the perineum is exposed 20. Prepares medication: a. Removes the wrapper from the suppository and places loosely in wrapper container 254 Procedure Steps Yes No Comments b. Or fills applicator according to the manufacturer's instructions 21. Uses only a water soluble lubricant 22. Inspects and cleans around the vaginal orifice; as needed 23. Administering a Suppository: a. After donning procedural gloves, applies a water- soluble lubricant to the rounded end of the suppository and to the gloved index finger on the dominant hand b. Separates the labia with the gloved nondominant hand c. Inserts the suppository as far as possible along the posterior vaginal wall (about 3 inches; Scm). If the suppository comes with an applicator, places the suppository in the end of the applicator, inserts the applicator into the vagina, and presses the plunger d. Asks patient to remain in a supine position for 5- 15 minutes. May elevate patient's hips on a pillow 24. Applicator Insertion of Creams, Foams or Jelly: a. Separates the labia with nondominant hand b. Inserts the applicator approximately 3 inches into vagina along the posterior vaginal wall c. Depresses the plunger, emptying medication into the vagina d. Disposes of the applicator or places on a paper towel; if reusable e. Asks patient to remain supine for 5 - 15 minutes f. Reassesses for therapeutic and side effects g. Places bed in lowest position h. Assures side rails are up on bed i. Places call light in reach j. Washes hands k. Documents the medication given in the patients record Recommendation: Pass______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______255 Procedure Checklist Administering Rectal Suppository Check ( ...J ) Yes or No Procedure Steps Yes No Comments 1. Check MD order- Checks the medication order against the Medication Administration Record (MAR); patient name, patient birthdate, medication, dose, route, time & allergies 2. Follows agency policy for medication administration, including the time frame for medication administration (most agencies allow medications to be given 30 minutes before or 30 minutes after the time indicated in the MAR) 3. Knows drug information, including drug action, purpose, recommended dosage, time of onset and peak action, common side effects, contraindications, drug interactions, nursing implications 4. Determines if medication dosage is appropriate for patient's age and weight 5. Identifies any special considerations for medication preparation and administration 6. Attains medication from medication cart/computer 7. First Check: Checks medication against MAR (medication, dose, time, route and expiration date) 8. Second Check: Checks medication against MAR (medication, dose, time, route and expiration date) 9. Calculates dosage accurately (if needed) 10. Washes hands upon entering patients room 11. Identifies patient by two methods 12. Provides for privacy 13. Explains procedure 14. Teaches patient about the medication 15. Third Check: At bedside, verifies medication, expiration date, dose, route, time and presence of drug allergies 16. Asks if patient needs to defecate prior to the suppository insertion 17. Assists patient to the Sims position; left side when administering laxatives 18. Dons gloves 19. Removes the suppository wrapper and lubricates the smooth end of the suppository and tip of the gloved index finger 20. Explains that there will be a cool feeling from the lubricant and feeling of pressure during insertion . 26. Asks patient to try to retain the suppository if he or she is able. If he or she has difficulty retaining the suppository, after removing finger from the anus, holds the buttocks together for a few seconds 27. Wipes the anus with tissue or absorbent cloth 28. Explains to patient the need to remain on a side-lying position for 5- 10 minutes 29. Disposes of used materials into a biohazard receptacle and washes hands thoroughly 30. Leaves the call light and bedpan within reach if suppository is a laxative 31. Reassesses for therapeutic and side effects 32. Places bed in lowest position 33. Assures side rails are up on bed 34. Places call light in reach 35. Washes hands 36. Documents the medication given in the patients record Recommendation: Pass ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 257 Inhaled & Nasal Drug Administration . . Skill.of the Week Objectives & Ac!ivities • Utilize the rights of drug administration for inhaled & nasal medications • List the advantaqes and disadvantaqes of inhaled & nasal medications Respiratory Handheld inhalers with and without spacers Respiratory inhalants produce fine droplets that are inhaled deep into the respiratory tract. They are absorbed immediately into the lining of the patient's bronchi or alveoli and then to the bloodstream. They produce both local and systemic effects. Commons Types: • Bronchodilators- improve airway patency, used to treat bronchospasms, asthma, and allergic reactions. • Mucolytics - used to liquefy thick bronchial secretions. • Corticosteriods - anti-inflammatory agents. Metered Dose Inhaler • Insert MDI canister into the holder. Remove mouthpiece cover from inhaler & shake inhaler well • Have client take a deep breath and exhale. • Instruct the client to position the inhaler in one of two ways (see right). • Inhale deeply & slowly through mouth while fully depressing medication canister, hold breath for approximately 10 seconds & then exhale through pursed lips. Using Spacer or Aerochamber • Insert MDI into end of spacer. • Have client place aerochamber mouthpiece in mouth & close lips, avoid covering small exhalation slots with lips. Depress MDI prescribed puffs into aerochamber. • Instruct client to breathe slowly & fully for 3 to 5 seconds, then hold a full breath for 10 seconds, removing MDI and spacer before exhaling. Using Dry Powder Inhaler • Remove cover from mouthpiece, turn wheel to right & left until click is heard. • Have client exhale away from inhaler prior to inhalation, position mouthpiece between the lips & inhale deeply & forcefully through the mouth. Hold breath for 5-1 0 seconds. Patient teaching for respiratory inhalers 1. Instruct patient regarding the drug's dose, purpose, adverse side effects and when to notify the doctor. 2. Warn patient against using the inhaler rnore often than ordered by the doctor because drug can lose its effectiveness. 3. Tell patient to rinse mouth after using the inhaler to prevent oral fungal infection. 4. Teach patient to wait 5 minutes between inhalers if they use both a bronchodilator and corticosteriod inhalers always use the bronchodilator first. 5. Teach patient to wait at least 1 minute between doses of a single inhaled drug. 6. Instruct patient using a corticosteriod inhaler to carry medical information stating this. This patient may need supplemental corticosteriods during severe stress or a severe asthma attack. 7. Provide written instructions. 258 Nasal Drugs Drops are usually used to treat a specific nasal area and sprays and aerosols to diffuse the drug through the nasal passages. Commonly administered nasal drugs: • Vasoconstrictors- coat and shrink swollen mucous membranes. • Local anesthetics- promote patient comfort during medical procedures. • Corticosteriods - reduce inflammation caused by allergies or nasal polyps. Key points • Push gently on tip of nose to open nostril completely • Stay with patient after administering nasal medications (observe for possible respiratory problems Maxillary and Frontal • Supine with head tilted toward affected side hanging slightly over bed • Slight hyperextension • Ordinary nasal congestion e Supine position with head tilted toward affected side • Aim the dropper upward toward the patient's eye, rather than down towards ear. Patient teaching for nasal drugs 1. Instruct patient regarding the purpose of the drops, spray or aerosol, adverse side effects to watch for and when to notify the doctor. 2. Explain the need for proper positioning when drops are given. 3. Explain the importance that tip of nozzle on sprays placed appropriately- just inside nostril- to ensure proper delivery of drug. 4. Teach patient to breathe through mouth during instillation. 5. Have the patient or significant other perform procedure with supervision and provide written instructions. Technique • Have client breathe through mouth. • Hold dropper 1 em above nares and instill prescribed number of drops toward midline of ethmoid bone. • Have client maintain supine position for 5 minutes. • Offer tissue but caution against blowing for several minutes. 259 Procedure Checklist Administering Medications Metered-Dose Inhaler Medication Check ( --1 ) Yes or No Procedure Steps Yes No Comments 1. Check MD order- Checks the medication order against the Medication Administration Record (MAR); patient name, patient birthdate, medication, dose, route, time & allergies 2. Follows agency policy for medication administration, including the time frame for medication administration (most agencies allow medications to be given 30 minutes before or 30 minutes after the time indicated in the MAR) 3. Knows drug information, including drug action, purpose, recommended dosage, time of onset and peak action, common side effects, contraindications, drug interactions, nursing implications 4. Determines if medication dosage is appropriate for patient's age and weight 5. Identifies any special considerations for medication preparation and administration 6. Attains medication from medication cart/computer 7. First Check: Checks medication against MAR (medication, dose, time, route and expiration date) 8. Second Check: Checks medication against MAR (medication, dose, time, route and expiration date) 9. Calculates dosage accurately (if needed) 10. Identifies the amount of medication for inhalation remaining in the canister. Based on the start date and instructions for use, a determination can be made about the number of remaining inhalations. Replaces the canister promptly when the canister is nearly empty 11. Washes hands upon entering patient's room 12. Identifies patient by two methods 13. Provides for privacy 14. Explains procedure 15. Teaches patient about the medication 16. Third Check: At bedside, verifies medication, expiration date, dose, route, time and presence of drug allergies 17. Assists patient to a seated position (if able) 18. Asks patient to rinse out mouth and to spit the rinse out (not swallow) 260 Procedure Steps Yes No Comments 19. Shakes the inhaler. Removes the mouthpiece cap of the inhaler and inserts the mouthpiece into the spacer while holding the canister upright 20. Removes the cap from the spacer 21. Asks patient to breath out slowly and completely 22. Places the spacer mouthpiece into the patient's mouth and have patient seal lips around the mouthpiece. Sharply presses down on the inhaler canister to discharge one puff of medication into the spacer 23. Asks patient to slowly inhale and then hold breath for as long as possible. Encourages patient to hold breath for 10 seconds if possible 24. If a second puff is needed, waits at last 1 minute before repeating inhalation steps 25. If a corticosteroid inhaler is used, assists patient to rinse out mouth with water and spit out the rinse 26. Cleans the mouthpiece with tissue or moist cloth and replaces the cap. Periodically rinses the spacer, mouthpiece and cap with water 27. Reassesses for therapeutic and side effects 28. Places bed in lowest position 29. Assures side rails are up on bed 30. Places caii light in reach 31. Washes hands 32. Documents the medication given in the patients record Recommendation: Pass, ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 261 Procedure Checklist Administering Nasal Medications Check ( .Y ) Yes or No Procedure Steps Yes No Comments 1. Check MD order- Checks the medication order against the Medication Administration Record (MAR); patient name, patient birthdate, medication, dose, route, time & allergies 2. Follows agency policy for medication administration, including the time frame for medication administration (most agencies allow medications to be given 30 minutes before or 30 minutes after the time indicated in the MAR) 3. Knows drug information, including drug action, purpose, recommended dosage, time of onset and peak action, common side effects, contraindications, drug interactions, nursing implications 4. Determines if medication dosage is appropriate for patient's age and weight 5. Identifies any special considerations for medication preparation and administration 6. Attains medication from medication cart/computer 7. First Check: Checks medication against MAR (medication, dose, time, route and expiration date) 8. Second Check: Checks medication against MAR (medication, dose, time, route and expiration date) 9. Calculates dosage accurately (if needed) 10. Washes hands upon entering patient's room 11. Identifies patient by two methods 12. Provides for privacy 13. Explains procedure 14. Teaches patient about the medication 15. Third Check: At bedside, verifies medication, expiration date, dose, route, time and presence of drug allergies 16. Explains to patient that the medication may have an unusual taste or cause some burning or tingling 17. Dons gloves 18. Asks patient to blow nose 19. Determines head position depending on patient's ability to assume the position: a. Assists patient with positioning either head down and forward or sitting and leaning forward 262 Procedure Steps Yes No Comments b. To medicate ethmoid and sphenoid sinuses, assists patient into the supine position with head over the edge of the bed. Supports the head. Alternatively, places a towel roll behind the shoulders, allowing the head to drop back c. To medicate frontal and maxillary sinuses, positions as in step b, but tilts the head toward the affected side d. If patient is unable to assume one of those positions, asks patient to tilt head back. 20. Asks patient to close one nostril and exhale, then inhale deeply through the nose 21. Administers spray or drops while patient is inhaling through the mouth. Does not touch the dropper to the sides of the nostril 22. Repeats the same on the other nostril 23. If nose drops are used, asks patient to stay in the same position for 1 - 5 minutes (following manufacturer's guidelines) 24. Instructs patient not to blow his nose for several minutes 25. Reassesses for therapeutic and side effects 26. Places bed in lowest position 27. Assures side rails are up on bed 28. Places call light in reach 29. Washes hands 30. Documents the medication given in the patients record Recommendation: Pass. ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 263 Procedure Checklist Administering Ophthalmic Medications Check ( ...J ) Yes or No Procedure Steps Yes No Comments 1. Check MD order- Checks the medication order against the Medication Administration Record (MAR); patient name, patient birthdate, medication, dose, route, time & allergies 2. Follows agency policy for medication administration, including the time frame for medication administration (most agencies allow medications to be given 30 minutes before or 30 minutes after the time indicated in the MAR) 3. Knows drug information, including drug action, purpose, recommended dosage, time of onset and peak action, common side effects, contraindications, drug interactions, nursing implications 4. Determines if medication dosage is appropriate for patient's age and weight 5. Identifies any special considerations for medication preparation and administration 6. Attains medication from medication cart/computer 7. First Check: Checks medication against MAR (medication, dose, time, route and expiration date) 8. Second Check: Checks medication against MAR (medication, dose, time, route and expiration date) 9. Calculates dosage accurately (if needed) 10. Washes hands upon entering patient's room 11. Identifies patient by two methods 12. Provides for privacy 13. Explains procedure 14. Teaches patient about the medication 15. Third Check: At bedside, verifies medication, expiration date, dose, route, time and presence of drug allergies 16. Assists patient to a high fowler's position with head slightly tilted back 17. Dons gloves 18. If needed, cleans the edges of the eyelid from the inner canthus to the outer canthus 19. Instilling Eye Drops: Holding the eyedropper, rests the dominant hand on patient's forehead 264 Procedure Steps Yes No Comments 20. With the nondominant hand, pulls the lower lid down to expose the conjunctival sac 21. Positions eyedropper 1.5- 2.0 em (1/2-% in.) above the patient's eye; does not let the dropper touch the eye. Asks patient to look up; drops the correct number of drops into the conjunctival sac. Does not drop onto cornea 22. Asks patient to gently close and move eyes 23. If the medication has a localized effect, presses gently against the same side of the nose to close the lacrimal duct for 1 - 2 minutes 24. Administering Eye Ointment: a. Rests the dominant hand, with eye ointment, on patient's forehead b. With the dominant hand, pulls the lower lid down to expose the conjunctival sac c. Asks patient to look up d. Applies a thin strip of ointment (about 1") in conjunctival sac; twists wrists to break off the strip of ointment e. Does no let the tube touch the eye f. Asks patient to gently close eye for 2- 3 minutes g. Explains that vision will be blurred for a short time 25. Reassesses for therapeutic and side effects 26. Places bed in lowest position 27. Assures side rails are up on bed 28. Places call light in reach 29. Washes hands 30. Documents the medication given in the patients record Recommendation: Pass, ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 265 Procedure Checklist Administering Otic Medications Check ( --./ ) Yes or No Procedure Steps Yes No Comments 1. Check MD order- Checks the medication order against the Medication Administration Record (MAR); patient name, patient birthdate, medication, dose, route, time & allergies 2. Follows agency policy for medication administration, including the time frame for medication administration (most agencies allow medications to be given 30 minutes before or 30 minutes after the time indicated in the MAR) 3. Knows drug information, including drug action, purpose, recommended dosage, time of onset and peak action, common side effects, contraindications, drug interactions, nursing implications 4. Determines if medication dosage is appropriate for patient's age and weight 5. Identifies any special considerations for medication preparation and administration 6. Attains medication from medication cart/computer 7. First Check: Checks medication against MAR (medication, dose, time, route and expiration date) 8. Second Check: Checks medication against MAR (medication, dose, time, route and expiration date) 9. Calculates dosage accurately (if needed) 10. Washes hands upon entering patient's room 11. Identifies patient by two methods 12. Provides for privacy 13. Explains procedure 14. Teaches patient about the medication 15. Third Check: At bedside, verifies medication, expiration date, dose, route, time and presence of drug allergies 16. Dons gloves 17. Warms the solution to be instilled (e.g., in hand or in warm, not hot water) and gently shakes the bottle before using the drops 18. Assists patient to a side-lying position, with the appropriate ear facing up 19. Cleans the external ear with a cotton-tipped applicator; if needed 20. Fills the dropper with the correct amount of medication .000 Procedure Steps Yes No Comments 21. For infants and young children, asks another caregiver to immobilize the child while administering the medication 22. Straightens the ear canal: a. For patients older than 3 years, pulls the pinna upward and back b. For children younger than 3 years old, pulls the pinna down and back 23. Instills the correct number of drops along the side of the ear canal 24. Does not touch the end of the dropper to any part of the ear 25. Gently tugs on the external ear after drops are instilled 26. Instructs patient to remain on his or her side for 5- 10 minutes 27. Places cotton loosely at the opening of the auditor canal for 15 minutes 28. Reassesses for therapeutic and side effects 29. Places bed in lowest position 30. Assures side rails are up on bed 31. Places call light in reach 32. Washes hands 33. Documents the medication given in the patients record Recommendation: Pass ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 267 Gavage/Lavage - NG/GT Medications Skill of the Week Objectives & Activities ·.· • Identify when tube feedings are used • Explain/demonstrate continuous and bolus/intermittent feedings • Be aware of hazards of NG suctioning & feedings • Check placement of an NG tube that has already been inserted • Correctly administer meds by NG or G tube Gavage & Decompression Oral feeding is the best way to receive nutrients; one can receive nutrition in two other ways: 1. Enteral nutrition: through the gastrointestinal system 2. Parenteral nutrition: through blood vessels (peripheral or central) Gastrointestinal tract is considered to be a clean area rather than a sterile one. The procedures used to place and flush an NG are performed using aseptic (clean) technique unless placed during surgery. Gavage: Nutritional supplement of high calorie liquid diets through a tube. • Provided at room temperature to avoid cramping. • May be bolus (given intermittently) or continuous. • Started at lower rates/amounts and gradually increased to assess for client tolerance. • Daily weights until maximum administration rate reached, then q 3 days. • Glucoscan q6h until max rate/amount, then q24h. NG (nasogastric tube)- from nose to stomach • Gastric acids decrease risk of infection (aseptic technique) o Not permanent, usually < 4 wks NJ- from nose to duodenum or jejunum PEG (Percutaneoous Endoscopic Gastrostomy tube or G-Tube)- through the abdominal wall into the stomach NG Purposes • Decompression - connected to suction to decrease gastric pressure by emptying gastric juices or gas (bowel obstruction or surgery) • Diagnosis -obtain specimens for lab analysis of acid levels and blood content o Compression -to apply pressure for hemorrhage • Lavage -wash gastric contents out or dilute irritants or poisons Placement (You must check institutional policies for the correct procedure) 1. Auscultation of insufflated air: place diaphragm of stethoscope just below client's xyphoid process, epigastric region. Use syringe to instill 20-30 ml of air and listen for a clear swoosh of air. 2. Visualization of aspirate: use a 60 ml syringe, try to aspirate fluid. If you can't inject 20 ml of air and try again. Observe aspirated fluid for clarity, color, and quantity. Gastric contents tend to be cloudy, green, tan off-white, bloody, or brown. Small bowel contents are generally distinctly yellow to bile colored. Respiratory aspirates are often pale yellow, serous or tan, off white or bloody. 3. Testing pH: Apply pH paper to aspirate. Generally gastric pH is< 4, small bowel> 268 4, and respiratory is > 5.5. Ongoing Care 1. Oral care: dry mouth, glycerin swabs, lemon swabs, toothbrush and paste, lubricate lips every 2-4 hours. 2. Nasal care: nares becomes dry, lubricate, moisture 3. Potency of suction: assess lines, connections, disconnect to hear swish of suction, place blue pigtail above the level of the heart and safety pin. 4. Abdominal assessment: assess for hypoactive bowel sounds, abdominal distention, abdominal pain, nausea, or vomiting (s/s of gastric retention) Complications of Gastric Suction 1. Nasal ulceration: improper taping of NG to nostril 2. Gastric ulceration: Levine connected to continuous suction and not intermittent low suction, blue vent on Salem obstructed. 3. Electrolyte imbalance: due to aspirated fluid being removed contains many electrolytes and not being replaced, hypokalemia may result. Complications of Feedings (Gavage) 1. Aspiration: improper placement, not evaluated for placement, not checked for residual, head of bed placed < 30-40 degrees 2. Potential for clogged tube: not flushed after medications, feedings, or every 4 hours if not connected to automatic tube feeding with flushing. 3. Electrolyte imbalance: due to high osmolarity concentration from solution causing diarrhea or Gl infection from not using aseptic technique 269 Procedure Checklist Administering Feedings through Gastric and Enteral Tubes Check ( .Y ) Yes or No Procedure Steps Yes No Comments 1. Check MD order to determine the type of feeding, rate of infusion, and frequency of feedings 2. Check the medical record to determine that tube placement has been confirmed by radiography before first feeding (or follow facilities' policy) 3. Washes hands 4. Obtains feedings and supplies 5. Checks the expiration date of the feeding formula 6. Shakes the feeding formula to mix well 7. Warms the formula to room temperature for intermittent feedings; for continuous feedings, keep formula cool but not cold 8. Prepares equipment for administration: For an Open System with Feeding Bag: a. Fills a disposable tube feeding (TF) bag with a 4- 6 hour supply of formula; primes tubing b. Labels the TF bag with date, time, formula type and rate c. Hangs the TF bag on an IV pole 9. For an Open System with Syringe: a. Prepares the syringe by removing the plunger b. Pours TF formula into syringe 10. For a Closed System with Prefilled Bottle with Drip Chamber: a. Attaches the administration set to prefilled bottle and primes tubing b. Hangs the prefilled bottle on an IV pole For all types of feedings 11. Washes hands upon entering patient room 12. Identifies patient by two methods 13. Provides for privacy 14. Explains procedure 15. Elevates the head of the bed at least 30° to 45° 16. Places a linen saver pad or towel under the connection end of the TF tube 17. Dons procedure gloves '>'7n Procedure Steps Yes No Comments 18. Attaches syringe to connection end of the feeding tube to check tube placement a. Aspirating stomach contents and measuring pH b. Asking patient to speak c. Measuring the external length of the tubing d. For nasogastric tubes, but not for gastrostomy or jejunostomy tubes, can additionally confirm by injecting air into the tube and auscultating for 11 Whooshu 19. For subsequent feedings, aspirate and measure the gastric residual (except for jejunostomy tubes) a. Connects the syringe to the proximal end of the feeding tube. Draws back slowly to aspirate b. Measures the volume of aspirated contents using a syringe (If volume is .60ml, uses graduated container, reinstills aspirate 20. Flushes the feeding tube with 30m I of water Beginning the Feedings: 21. If using an infusion pump: a. Hang feeding and prime tubing (unless already done on previous step). Threads the administration tubing through the infusion pump according to the manufacturer's instructions b. Clamps or pinches of the end of the feeding tubes c. Traces the tubing from the bag back to the patient d. If a connector is needed, attaches it to the open end of the feeding tube and connects to the distal end of the administration tubing. If no connector is needed, attaches the distal end of the administration tubing to the proximal (open) end of the feeding tube e. Turns on the infusion pump; sets the correct infusion rate and volume to be infused f. Unclamps the tube; begins infusion 22. If Using an Open System and Syringe: a. Clamps or pinches off the end of the feeding tube b. Attaches the syringe to the proximal (open) end of the feeding tube c. Fills the syringe with the prescribed amount of formula d. Releases the tube clamp or pinch and elevates the syringe. Does not elevate syringe .18/ inches above the tube insertion site 271 Procedure Steps Yes No Comments e. Allows feedings to flow slowly (if too fast, lowers the syringe) f. When the syringe is nearly empty, clamps tube or holds it about the level of the stomach; refills the syringe; unci amps and continues feedings until done 23. Using a Closed-System with a Pre-filled bottle with a drip chamber (no infusion pump): a. If connector is needed, attaches to the proximal (open) end of the feeding tube and connects to administration tubing. If no connector is needed, attaches the distal end of the administration tube to the proximal (open) end of the feeding tube. Traces tubing from the bag back to patient 24. Begins the infusion: Opens the roller clamp on the administration tubing and regulates the flow to the prescribed rate End Feedings: 25. When feeding is infused, proceeds as follows: a. Turns off the pump, pinches the end of the feeding tube, and flushes with the prescribed amount of water b. Open System Syringe: Disconnects the syringe from the feeding tube, flushes the tube with approximately 50ml of water c. Closed System with Prefilled Bottle with Drip Chamber: Turns off the pump or turns the roller clamp off. Disconnects the feeding tube from the administration tubing. Flushes the feeding tube with prescribed amount of water d. Continuous Feeding: Flushes the tube with the prescribed amount of water (typically 50- 1OOml) every 4- 6 hours 26. Caps the proximal end of the feeding tube 27. Keeps the head of the bed elevated at least 30° to 45° for 1 hours after TF is infused 28. Provides frequent oral hygiene and gargling 29. Washes hands 30. Procedure Variation for Gastrostomy Tubes and Gastric Buttons: Cleans insertion site daily with soap and water. A small, precut, gauze dressing may be applied to the site 272 Recommendation: Pass. ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 273 Procedure Checklist Administering Feedings Through an Enteral Tubes Check ( .Y ) Yes or No Procedure Steps Yes No Comments 1. Check MD order- Checks the medication order against the Medication Administration Record (MAR); patient name, patient birthdate, medication, dose, route, time & allergies 2. Follows agency policy for medication administration, including the time frame for medication administration (most agencies allow medications to be given 30 minutes before or 30 minutes after the time indicated in the MAR) 3. Knows drug information, including drug action, purpose, recommended dosage, time of onset and peak action, common side effects, contraindications, drug interactions, nursing implications 4. Determines if medication dosage is appropriate for patient's age and weight 5. Identifies any special considerations for medication preparation and administration 6. Attains medication from medication cart/computer 7. First Check: Checks medication against MAR (medication, dose, time, route and expiration date) 8. Second Check: Checks medication against MAR (medication, dose, time, route and expiration date) 9. Calculates dosage accurately (if needed) 10. Crushes medication in medication package (Making sure medication can be crushed prior to crushing) 11. Washes hands upon entering patient's room 12. Identifies patient by two methods 13. Provides for privacy 14. Explains procedure 15. Third Check: At bedside, verifies medication, expiration date, dose, route, time and presence of drug allergies 16. Opens medication and places in medication cup without touching medication (If liquids, shake medication and pour into cup, at eye level, from the side of the container away from the label) 17. Mixes medication with approximately 20m I of water 18. If several medications are given, mixes all medication in same medication cup; unless otherwise contraindicated 19. Performs any assessments that are related to the medication to be given, such as checking the pulse and blood pressure Procedure Steps Yes No Comments 20. Places patient in a high-Fowler's position if possible 21. Checks nasogastric tube for placement by aspirating stomach contents or measuring the pH of the aspirate, if possible. Other, less accurate methods are injecting air into the feeding tube and auscultating or asking patient to speak 22. Checks for residual volume (making sure all residual volume is placed back into the tube) 23. Flushes the tube, uses the correct type of size syringe 24. To flush the tube, removes the bulb or plunger from the syringe, attaches barrel to the tube and pours in 30m I of water 25. Instills medication by using the barrel of the syringe as a funnel and pouring in the medication 26. Flushes the medication through the tube by instilling an additional 30m I of water 27. Has patient maintain a sitting position (if able) for at least 30 minutes after medication administration 28. Reassesses for therapeutic and side effects 29. Teaches patient about the medication (if able) 30. Washes hands 31. Documents the medication given in the patients record Recommendation: Pass ______Needs more practice ______ Student: ______Date: ______ Instructor: ______Date: ______ 275 Merced College A ute M di 1/ urgical and Nursing of th hildb a ring mil Spring 2014 Dan Smith, RN, MSN, FNP Kitty Cazares~ RN, MSN T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Cover.docx 12/9/13 Merced College REGN 24-Nursing in Health & Illness II Table of Contents Section A- Introductory Materials ...... 1 Course Outline ...... 2 SL0 ...... 5 Time Guidelines for Clinical Lab Skills ...... 1 0 Grading Criteria ...... 11 ATI Grading ...... 12 Section B - Theory Objectives - Kitty Cazares ...... 13 Theory Schedule ...... 14 Care of the Perioperative Patient ...... 15 Care of the Pediatric Client with Infectious Diseases ...... 16 Infectious Diseases-Child ...... 17 Common Conditions of the Cardiovascular System ...... 19 Anemias ...... 20 Care of the Adult Client with Dyspnea ...... 21 Alterations in Gastrointestinal Function ...... 22 Common Alterations in Urinary Function ...... 23 Care of the Patient with Diabetes Mellitus ...... 24 Care of Elderly Patients ...... 25 Cerebrovascular Disorders ...... 26 Alterations in Musculoskeletal or Articular Function ...... 27 Coronary Chest Pain Characteristics ...... 28 Section C- Theory Objectives- Dan Smith ...... 29 Topical Outline/Title in Bold ...... 30 Care of the Childbearing Family: Pregnancy ...... 32 Introduction to Maternity & Reproductive Health ...... 33 Genetics & Fetal Development/Anatomy & Physiology of Pregnancy ...... 34 Nursing Care During Pregnancy/Maternal & Fetal Nutrition ...... 35 Labor and Delivery/Postpartum ...... 36 Labor & Delivery/Managing Discomfort/Fetal Assessment ...... 37 Assessing High Risk Pregnancy/Labor & Birth ...... 38 Postpartum Care/Complications in the Postpartum Period ...... 39 Care of the Newborn ...... 40 T:\RN-L VN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 20 13\REGN 24\Table of Contents.docx January 6, 2014 Postpartum Maternal Physiological Changes/Family Transition ...... 41 Newborn Care & Nursing Care of the Newborn ...... 42 APGAR Score ...... 43 Complications of Newborn ...... 44 Section D - Clinical Information ...... 45 Scavenger Hunt ...... 46 Section E- Outmigration Information ...... 48 Outmigration Clinicallnstructions ...... 49 Pediatric Clinic Guidelines ...... 50 "If you have a verified physical, medical, psychological, or learning disability or perhaps you feel you may have one of these disabilities which impact your ability to carry out assigned course work, please contact the Disabled Student Services (DSS) office. DSS staff will review your needs and determine what accommodations are necessary and appropriate. All information and documentation is confidential. DSS is located in the Lesher Student Services Bldg. Room 234, phone 384-6155. In Los Banos, DSS is located in Building A, phone 381-6423." T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 20 13\REGN 24\Table of Contents.docx January 6, 2014 ti n lntr ductory M terials T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Dividers.wpd January 6, 2014 1 Merced College Course Outline 1. Course Number and Title: REGN 24, Acute Medical/Surgical and Nursing of the Childbearing Family 2. Units: 10 Hours: Lecture 5; Lab 15 3. Prerequisite: Completion of REGN 15, REGN 18 Advisory: none 4. Catalog Description: REGN-24 provides for the acquisition and application of nursing theory, communication, collaboration, and critical thinking skills necessary for safe, patient-centered nursing care to a developmentally and culturally diverse patient population experiencing various common medical/surgical interventions and to the childbearing family. Incorporates best practices, professional standards, and legal and ethical responsibilities of the professional nurse as applied in various healthcare settings. Includes acquisition of nursing skills required in acute care and childbearing family settings. Application of knowledge and skills occurs in the nursing skills laboratory and clinical settings. Registered Nursing 24 Course Outcomes: 1. Apply medical/surgical and childbearing family nursing concepts to plan patient centered, evidence-based care taking into consideration individual differences, developmental level, and culture. 2. Identify the collaborative role of the nurse when working with the interdisciplinary team when caring for the childbearing family and patients requiring medical/surgical interventions. 3. Demonstrate critical thinking/clinical reasoning when caring for the childbearing family and patients requiring medical/surgical interventions. 4. Implement basic leadership concepts for the purpose of providing and improving care for the childbearing family and patients requiring medical/surgical interventions. 5. Use information technology to document care for the childbearing family and patients requiring medicaiisurgicai interventions. 6. Identify ways in which professional standards of legal and ethical conduct apply to safe, quality, patient-centered care for the childbearing family and patients requiring medical/surgical interventions. 5. Required Texts and Supplies: Medical-Surgical Nursing: Patient-Centered Collaborative Care; lgnatavicius, D., Saunders Maternity Nursing w/Study Guide; Lowdermilk & Perry, gth, Mosby Wong's Essentials of Pediatric Nursing; Hockenberry, gth, Mosby ATI Resources T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Course Outline.wpd December 9, 2013 2 6. Entrance Skills: Prerequisite Skills: Before entering the course the student should be able to: REGN 15 and REGN 18: Complete Universal, Conceptual, and Clinical objectives identified in course outlines. 7. Course Outcomes and Competencies: 1. Apply medical/surgical and childbearing family nursing concepts to plan patient centered, evidence-based care taking into consideration individual differences, developmental level, and culture. Apply medical/surgical and childbearing family nursing concepts to plan compassionate, patient-centered, evidence-based care taking individual differences into consideration. Conduct, at a basic level, a comprehensive and focused physical, behavioral, psychological, spiritual assessment of medical/surgical patients and childbearing families, eliciting patient values, experiences, and expressed needs. Plan holistic, patient-centered care that reflects psychosocial integrity, physiological integrity, and health promotion and maintenance of medical/surgical patients and childbearing families within a variety of healthcare systems. • Demonstrate at a basic level, the application of psychomotor skills for the efficient, safe, and compassionate delivery of patient care. Deliver care within expected timeframe. Monitor at a basic level patient outcomes, including interpretation of assessment data and appropriate follow-up, to evaluate the effectiveness of nursing interventions. Describe the clinical microsystem of the medical-surgical and maternal-newborn units. • Identify quality measures when evaluating effects of medical-surgical and childbearing family nursing interventions appropriate to the care environment. Describe factors that create a culture of caring for the patient and the patient's support network. Communicate effectively with the patient and the patient's support network. • Communicate effectively when reporting care provided and evaluation data including appropriate handoff reports. • Provide at a basic level appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and level of health literacy. Evaluate effectiveness of patient teaching. 2. Identify the collaborative role of the nurse when working with the interdisciplinary team when caring for the childbearing family and patients requiring medical/surgical interventions Use effective communication techniques that produce positive professional working relations in the medical-surgical environment. Interact with members of the healthcare team to plan patient care and evaluate progress toward patient outcomes for the patient undergoing medical/surgical procedures and those of the childbearing family. Explain the nurse's role in decision making related to patient care in the medical/surgical and maternal-newborn environments. Identify examples of conflict resolution and describes possible solutions. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Course Outline.wpd December 9, 2013 3 Identify own role as a member of the interdisciplinary healthcare team working with medical/surgical patients and childbearing families. Describe ways in which team functioning impacts safety and quality improvement for the medical/surgical patient and childbearing families. 3. Demonstrate critical thinking/clinical reasoning when caring for the childbearing family and patients requiring medical/surgical interventions. Use critical thinking/clinical reasoning when planning patient care and working in the medical-surgical and maternal-newborn environments. Demonstrate tolerance for ambiguity and unpredictability and its effect on care of the medical-surgical patient and childbearing families. Interpret and correctly implement physician and interprofessional orders for the medical-surgical patient and childbearing families. Anticipate risks and predict and manage potential complications that commonly occur in the medical-surgical patient and childbearing families. Use the nursing process to make decisions about care for the medical-surgical patient and childbearing families. 4. Implement basic leadership concepts for the purpose of providing and improving care for the childbearing family and patients requiring medical/surgical interventions. • Begin to use the delegation process in the medical-surgical and maternal newborn settings. • Compare and contrasts the differences in the provision of patient care among various medical-surgical patients and childbearing families. Describe the effect of the nursing leadership on a medical-surgical and maternal newborn unit. Describe the quality improvement processes on a medical-surgical and maternal newborn unit used to effectively implement patient safety initiatives and monitor performance measures. Apply the National Patient Safety Goals to patients on a medical-surgical and maternal-newborn unit and identify any areas in need of improvement. 5. Use information technology to document care for the childbearing family and patients requiring medical/surgical interventions. Maintain organizational and client confidentiality. Explain how the clinical information system is used on the medical-surgical and maternal-newborn unit for safe nursing practice. Give examples of the role of information technology in improving patient care outcomes and creating a safe care environment on the medical-surgical and maternal-newborn unit. 6. Identify ways in which professional standards of legal and ethical conduct apply to safe, quality, patient-centered care for the childbearing family and patients requiring medical/surgical interventions. Apply rules and regulations that authorize and define professional nursing practice on the medical-surgical and maternal-newborn unit. Demonstrate professional standards of moral, ethical, and legal conduct when providing care for the medical-surgical patient and childbearing families. Assume accountability for own behaviors, including a recognition for when to ask for assistance. Practice within the parameters of individual knowledge and experience. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Course Outline.wpd December 9, 2013 4 Program Student Learning Outcomes Faculty believe in the importance of incorporating professional standards, guidelines, and competencies as the basis for the nursing curriculum. The program must reflect current nursing practice. To this end, a rigorous and thorough examination of the current literature on nursing practice and nursing education was conducted. These findings guided the development of the program student learning outcomes. Additionally, faculty examined the current healthcare environment in the Merced area. The program student learning outcomes, along with their related competencies, reflect the expected behaviors of the graduates of Merced's Nursing Program. Therefore, these program student learning outcomes are used to organize the curriculum, and guide all activities related to the teaching/learning process, including delivery of instruction and evaluation of student progress. The six student program learning outcomes are: 1. Provide quality, safe, patient-centered nursing care through evidence-based practice. 2. Participate in collaborative relationships with members of the interdisciplinary team to provide and improve patient care. 3. Engage in critical thinking skills and strategies and clinical reasoning necessary to provide quality patient care. 4. Provide leadership in a variety of healthcare settings for diverse patient populations. 5. Use information technology to communicate, manage knowledge, mitigate error, and support decision-making. 6. Function as a competent nurse assimilating all professional, ethical, and legal principles. The documentation from which these program student learning outcomes flow is presented in the next section. The Program Student Learning Outcomes align with Institutional Student Learning Outcomes as follows: 1. Provide quality, safe, patient-centered nursing care through evidence-based practice. Merced College outcome related to cognition: Assess the impact of science and technology on the world. Patient-centered relates to Merced College's outcome related to Global & Community Consciousness: Distinguish and understand diverse cuitures. 2. Participate in collaborative relationships with members of the interdisciplinary team to provide and improve patient care. Merced College outcome related to communication such as: Read and analyze written communication appropriate to the subject and Comprehend, anaiyze, and utiiize aural and visual communication in its various modes. 3. Engage in critical thinking skills and strategies and clinical reasoning necessary to provide quality patient care. Merced College outcome related to Use Critical thinking skills to analyze, synthesize, and evaluate ideas and information. 4. Provide leadership in a variety of healthcare settings for diverse patient populations. Merced College outcome related to Personal development and life-long learning: Demonstrate self-management, maturity, and growth through practices that promote physical, mental, and emotional well-being, such as: Analyze and apply interpersonal skills. 5. Use information technology to communicate, manage knowledge, mitigate error, and support decision-making. Merced College outcome related to communication such as: Comprehend, analyze, and utilize aural and visual communication in its various modes. 6. Function as a competent nurse assimilating all professional, ethical, and legal principles. Merced College outcome related to Personal development and life-long learning: T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Course Outline.wpd December 9, 2013 5 Demonstrate self-management, maturity, and growth through practices that promote physical, mental, and emotional well-being, such as: Demonstrate an understanding of life-long learning (professional principle) and Evaluate and adhere to professional and ethical standards. Sequencing of Courses The program is designed to culminate in these student learning outcomes. Therefore, each course is leveled based on these outcomes as well as populations of patients. The sequencing of courses reflects higher cognitive levels, a different patient population, and/or more complexity in patient care provided in a variety of healthcare settings. Patricia Benner's Model of Novice to Expert is used in the development of the professional nurse. Courses build to assist students with their journey to advanced beginner by graduation, prepared to become competent nurses as they experience their first two years of practice (Benner, Tanner, & Chesla, 2009). T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Course Outline.wpd December 9, 2013 6 Documentation for Development of Program Student Learning Outcomes Current trends in nursing and health care as well as traditional standards and values of nursing practice influenced the choice of these six program student learning outcomes. The following is an explanation of the specific current trends and traditional standards and values used to develop the program student learning outcomes. 1. Provide quality, safe, patient-centered nursing care through evidence-based practice. This outcome focuses on the many aspects of the nurse/patient relationship and integrates the work of the QSEN group derived from the IOM studies (Finkelman & Kenner, 2009). Safety is a major concept and is based on QSEN.org documentation as well as the NCSBN's Nursing Pathways for Patient Safety (201 0). The importance of patient-centered care is addressed by the Institute of Medicine (201 0) stating that many systems are designed to meet the needs of providers. "True patient- and family-centered care will focus on the whole patient, putting the patient, family, and care team together as a system" (p. 16). This outcome also relates to two of NLN's Competencies for ADN graduates (201 0): "Advocate for patients and families in ways that promote their self-determination, integrity, and ongoing growth as human beings" (p. 33), and "Implement one's role as a nurse in ways that reflect ..... a nurse committed to evidence-based practice, caring, and advocacy, and safe, quality care for diverse patients within a family and community context (p. 35). This outcome also embraces the major categories of content presented in the NCLEX-RN® test plan. The ANA's (201 0 Nursing: Scope and Standards of Practice are applied when planning quality, patient-centered nursing care. Major concepts for this learning outcome include: The nursing process (assessment, diagnosis, goals/outcome criteria, interventions, and evaluation) Patient teaching Patient-centered care Evidence-based practice Quality measures Caring Safety NCLEX-RN® categories and their subcategories: a. Safe and effective care environment b. Health promotion and maintenance c. Psychosocial integrity d. Physiological integrity 2. Participate in collaborative relationships with members of the interdisciplinary team to provide and improve patient care. The importance of collaboration is emphasized in the work of the QSEN group derived from the IOM studies (Finkelman & Kenner, 2009) with the competencies of Teamwork and Collaboration. The QSEN and IOM competencies of Quality Improvement and Patient-Centered Care also relate to this outcome. This outcome incorporates NLN's 2010 definition of teamwork: "to function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality care" (p. 69). The silo approach to care in which each professional works in parallel is no longer acceptable in the current healthcare environment. Health professionals must "cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable" (I OM, 2003, p. 4). Additionally, the Institute of Medicine (201 0) notes that 60 to 70% of adverse events happening to patients in the acute care setting can be traced to problems with communication. Some of those problems stem from disruptive behavior by both nurses and physicians. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Course Outline.wpd December 9, 2013 7 This program student learning outcome addresses the nurse's role in working with other healthcare professionals to plan and implement care and quality improvement measures. The importance of the broader context of a systems approach to care rather than the narrower nurse/patient relationship as the primary focus of the work environment is imperative for meeting the quality improvement competency for this outcome (Day & Smith, 2007). Major concepts for this learning outcome include: • Patient-centered care • Teamwork/collaboration • Quality improvement • Levels of the work environment: The larger healthcare system Clinical microsystems Nurse/patient relationship 3. Engage in critical thinking skills and strategies and clinical reasoning necessary to provide quality patient care. Critical thinking is a broad term that encompasses all the thought processes that relate to clinical decision making and clinical reasoning. It is part of the term NLN (201 0) defines as nursing judgment which encompasses three processes: critical thinking, clinical judgment, and integration of best evidence into practice (p. 67). The National Council of State Boards of Nursing (NCSBN) identified critical thinking as the number two attribute for entry level RNs (NCSBN, 2006). Critical thinking is evidenced not only by the student's use of the nursing process, but also when interfacing with the clinical microsystem and the larger healthcare system to deliver quality, safe, patient-centered care. This outcome also relates to two of NLN's Competencies for ADN graduates (201 0): "Make judgments in practice, substantiated with evidence, that integrate nursing science in the provision of safe, quality care and promote the health of patients within a family and community context" (p. 34) and "Examine the evidence that underlies clinical nursing practice to challenge the status quo, question underlying assumptions, and offer new insights to improve the quality of care for patients, families, and communities" (p. 36). Major concepts for this learning outcome include: • Critical thinking • Clinical decision making • Clinical judgment • Integration of best evidence • Nursing process 4. Provide leadership in a variety of healthcare settings for diverse patient populations. This outcome focuses on the core component of Leadership. Leadership is comprehensive and includes managing care, delegating to others, integrating and coordinating care, investigating and sharing best practice guidelines, and serving as a leader in many capacities within the healthcare environment. Another major component under leadership derives from the Quality and Safety Education in Nursing (QSEN) (2007) competency, Quality Improvement. Quality improvement refers to the use of data to monitor the outcomes of care processes and the use of improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems (Smith, Cronenwett, & Sherwood, 2007). This outcome also relates to two of NLN's Competencies for ADN graduates (201 0): "Advocate for patients and families in ways that promote their self-determination, integrity, and ongoing growth as human beings" (p. 33), and "Implement one's role as a nurse in ways that reflect integrity, responsibility, ethical practices and evolving identity .... .for diverse patients within a family and community context" (p. 35). T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Course Outline.wpd December 9, 2013 8 Major concepts for this learning outcome include: • Management of care • Delegation • Leadership • Quality improvement • Human flourishing 5. Use information technology to communicate, manage knowledge, mitigate error, and support decision-making. Traditionally, communication referred to engaging in verbal and written exchange of information. More recently it also includes using information and communication technologies. Knowledge and use of information systems and nursing informatics in health care mandates that students learn about new technologies. This program student learning outcome is a specific competency recommended by QSEN. Knowledge of informatics is also recommended by the NLN in their 2008 position statement Preparing the Next Generation of Nurses to Practice in a Technology-Rich Environment: An Informatics Agenda. In this position paper the NLN called for nursing schools to incorporate informatics into the curriculum. Major concepts for this learning outcome include: • Information systems • Nursing informatics • Information technology 6. Function as a competent nurse assimilating all professional, ethical, and legal principles. The general term professionalism is used to include all professional, ethical, and legal principles to guide the practice of the registered nurse. The foundation for this program student learning outcome flows from two American Nurses Association documents, Nursing: Scope and Standards of Practice and The ANA Code of Ethics as well as the California Board of Registered Nursing's Nurse Practice Act. This outcome also relates to one of NLN's Competencies for ADN graduates (201 0): "Implement one's role as a nurse in ways that reflect integrity, responsibility, ethical practices, and an evolving identity as a nurse committed to evidence-based practice, caring, advocacy, and safe, quality care for diverse patients within a family and community context" (p. 35). Personal and professional development is part of this competency which includes lifelong learning. Major concepts for this learning outcome include: e Professionalism • Ethical behavior • Legal principles • Standards of practice • Personal and professional development T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Course Outline.wpd December 9, 2013 9 Registered Nursing Program Time Guidelines for Clinical Lab Skills Time Bed Making ...... 15 Min Hand Washing ...... 5 Min Body Mechanics (Position/turn) ...... 15 Min Bed Bath ...... 15-20 Min Vital Signs ...... 10 Min Enema ...... 15 Min Restraint/Binder ...... 1 0 Min Adv. Body Mechanics ...... 15 Min (Transfer/amb/rom) Ng Insertion ...... 15 Min Sterile Gloving ...... 5 Min Dressing Change ...... 15 Min Catheter Insertion ...... 20 Min Oral Medication ...... 1 0 Min .... 1"\ 1\ .II: .... Specimens ...... IV lVIII! Subq Injection ...... 15 Min lm Injection ...... 15 Min Assessment ...... 15 Min Blood Sugar Testing ...... 20 Min Discontinue IV ...... 15 Min Suture/staple Removal ...... 15 Min Bandages ...... 15 Min Heat/cold ...... 1 0 Min Oral/nasal Suction ...... 1 0 Min Meds (Otic/ophthalmic/topical) ...... 1 0 Min T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 25\Time G~ctJiines.wpd July 17, 2013 Merced College REGN 24 - Nursing in Health and Illness II Second Semester Spring 2014- Grading Criteria Instructors: Kitty Cazares RN, MSN Dan Smith RN, MSN, FNP Room: AHC -102 Room AHC- 101 Telephone: 384-6386 Telephone: 384-6127 Office Hours: TBA Office Hours: TBA Theory and Clinical Objectives As outlined in Syllabus Grading Criteria 1. Theory Component Exams (5) 75 Final 20 ATI 5 2. Clinical Component Clinical Pass/Fail You must have a mini u course aveiage of 75°/o to pass this course. It is the instructor's right to make changes in the course schedule and learning activities as needed. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Faii2013\REGN 24\Grading Criteria- REGN 24.docx 12/9/13 11 ATI Grading To assist students in preparation for the proctored assessment, assigned readings from the ATI review module are provided. It is recommended that the student completes the application exercises and practice assessments, and create a focused review to address their areas needing improvement to be awarded points. Five percent of the course grade will be calculated (maximum of 5 points) as follows: preparing for the exam (2 points), and achieving various proficiency levels: Level 3 (3 points); Level 2 (2 points); Level 1 (1 point). Preparation for the proctored assessment is essential for student success. The items below are to provide students with tools to achieve success. In order to earn two points, the following needs to be completed, prior to taking the Proctored ATI Exam. 1. Attain 95°/o on the practice assessments Forms A & B. Practice assessments may only be taken once every seventy two (72) hours. Time begins upon completion of a practice assessment. The two points will be calculated as follows: completion of practice Form A (1 point), com1pletion of practice Form B (1 point), and not completing practice Forms A or B (0 points) . ...J. N **Approved Remediation 1. Students scoring below Level 1 are encouraged to contact their faculty member, by email or in person prior to beginning remediation. 2. The remediation plan is to create and complete a Focused Review on topics missed. The score received on the ATI proctored assessment will determine the required time in focused review. If you are unsure of how to create a focused review, go to the ATI website (www.atitesting.com), log-in and the instructions are located under Orientation Materials > How to Access My Results and Remediation > Page 5. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\ATl Grading.wpd ti n Th ry bje tiv Kitty az res T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Dividers.wpd January 6, 2014 13 Merced College REGN 25 - Nursing Skills Simulation II Theory Schedule Month Date Topical Outline January 13 Pre and Post-op Care 15 Infectious Diseases- Adult 20 HOLIDAY 22 Infectious Diseases - Child 27 Hypertension 29 EXAM #1 February 3 Introduction to Maternity- Nursing 5 Reproduction Concerns & Health Assessments 10 Genetics & Fetal Development 12 Anatomy & Physiology of Pregnancy 17 HOLIDAY 19 Nursing Care During Pregnancy I Maternal & Fetal Nutrition 24 EXAM #2 26 Labor & Birth Processes March 3 Nursing Care During Labor, including Managing Discomfort and Fetal Assessment 5 Assessment of High Risk Pregnancy 10 Labor & Birth At Risk 12 Postpartum Complications 17 Exam #3 19 Maternal Physiological Changes 24 Postpartum Nursing & Family Transition 26 Adaptations of the Newborn 31 Assessment of the Newborn April 2 The New At Risk 7 EXAM #4 9 ATI EXAM 14 Anemias 16 G I Alterations 21-25 Spring Break 28 GU Alterations 30 Client with Dyspnea May 5 EXAM #5 7 Client with CVA 12 Client with Chest Pain 14 Diabetes/Care of Immobilized Patient 19-22 Final Exam Week T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Faii2013\REGN 25\Theory Schedule REGN 24.docx 14 Care of the Peri operative Patient Purpose: This unit addresses care of diverse patients undergoing surgical intervention. Differentiation will be made between adult patients and pediatric patients undergoing general surgery. Extremely important to the care of the surgical patient is patient teaching. Teaching is a major factor in preventing postoperative complications. Experiences in the nursing skills laboratory include care of drains and sutures; staple removal, and sterile surgical setup. Learning Objectives and Course Outcomes Specific student learning objectives appear at the beginning of each chapter. These will be used as the focus of the content. The specific content is then related to the following course outcomes: 1. Apply surgical nursing concepts to plan patient-centered, evidence-based care taking into consideration individual differences, developmental level, and culture. 2. Identify the collaborative role of the nurse when working with the interdisciplinary team when caring for the surgical patient. 3. Demonstrate critical thinking/clinical reasoning when caring for the surgical patient. 4. Implement basic leadership concepts for the purpose of providing and improving care for the surgical patient. 5. Use information technology to document care for the surgical patient. 6. Identify ways in which professional standards of legal and ethical conduct apply to safe, quality, patient-centered care for the surgical patient. Major Topics 1. The perioperative experience 2. Nursing care of the surgical patient 3. Pain control Nursing Skills Laboratory 1. Sterile technique 2. Surgical scrub and sterile surgical setup 3. Care of drains and suture; staple removal 4. IV pain medications: IVP and PCA usage Required Reading lgnatavicius & Workman, Chapters 5, 16, 17, 18 Wilkinson & Van Leuven, Vol. 1, Chapter 37 Wilkinson & Van Leuven, Vol. 2, Chapter 37 T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Care of the Perioperative Patient. doc 1/3/14 15 Introduction to Care of Patients with Infectious Diseases Purpose: The unit discusses another common ailment, that of infectious diseases. In children, most infectious diseases are acute illnesses. With immunizations many of the devastating effects of infectious agents are controlled. However, acute infections are still a threat for both children and adults. Experiences in the nursing skills laboratory focus on intravenous infusions, a common intervention for patients hospitalized with infections. Starting an IV and adding medications to a solution are covered. Learning Objectives and Course Outcomes Specific student learning objectives appear at the beginning of each chapter. These will be used as the focus of the content. The specific content is then related to the following course outcomes: 1. Apply nursing concepts to plan patient-centered, evidence-based care taking into consideration individual differences, developmental level, and culture for the patient with an infectious illness. 2. Identify the collaborative role of the nurse when working with the interdisciplinary team when caring for the patient with an infectious illness. 3. Demonstrate critical thinking/clinical reasoning when caring for the surgical patient. 4. Implement basic leadership concepts for the purpose of providing and improving care for the patient with an infectious illness. 5. Use information technology to document care for the patient with an infectious illness. 6. Identify ways in which professional standards of legal and ethical conduct apply to safe, quality, patient-centered care for the patient with an infectious illness. Major Topics 1. Infection control 2. Health promotion and illness prevention 3. Nursing care of the patient with an infectious illness Nursing Skill Laboratory 1. Transmission-based precautions 2. Donning and removing personal protective equipment (PPE) Required Reading Hockenberry & Wilson, pages 423-432. lgnatavicius & Workman, Chapter 19, 25, 76 T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\lnto to Care of Patients with Infectious Diseases. doc 1/3/14 16 resp none rash blood supportive Koplik spots urine live virus Par~myxo~ resp none Affects parotid MMR v1rus fomites supportive gland SQ orchitis live virus resp immunoglobulin 3 day rash MMR ~ Ru.bella ...... I v1rus stool for pregnant tetragenic SQ urine women to fetus live virus blood Coryne- mucous equine airway obstruction OPT bacteriumT membranes antitoxin; damage to I IM dephtheriae skin dip, toxoid for nerve, heart, lesions contacts kidneys BordetellaT resp antimicrobials high pitched OPT pertussis Pertussis whooping sound I IM bacteria immune globulin Clostridiunn soil, dust, Hun:tan tetanus I muscle .stiff~ess---> I IM tetani bacillus I \t'later, animal Immune tetaruc se1zures mouths and feces T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\lnfectious Diseases - Child.wpd January 6, 2014 resp I acyclovir (oral) Herpes zoster virus varivax virus I skin lesions antipyretics of shingles SQ coli baths, live virus careful hygiene rash Enterovirus I oral no treatment motor neurons oral feces SQ virus I transfusion immune HbV injection globulin IM vaccine virus~ Gl diarrhea Mycobacterium PPD (diagnostic) ..:.. 1<'/'}":-':".. --·--.·.-->--:.;~:.-.-.- ,-- ,-·-- I I I co I H. Influenza Hib type b I I I I IM T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\lnfectious Diseases- Child.wpd January 6, 2014 Care of Patients with Common Conditions of the Cardiovascular System Purpose: The unit covers common alterations of the cardiovascular system. Cardiac disease is a major cause of death in this country so the nurse must be very mindful of complaints of chest pain or detection of hypertension during a physical examination. Hypertension is a common cause of both myocardial infarction and stroke. The common conditions covered in this unit include chest pain, dyspnea, hypertension, and stroke. Learning Objectives and Course Outcomes Specific student learning objectives appear at the beginning of each chapter. These will be used as the focus of the content. The specific content is then related to the following course outcomes: 1. Apply nursing concepts to plan patient-centered, evidence-based care taking into consideration individual differences, developmental level, and culture for the patient with chest pain, dyspnea, hypertension, and stroke. 2. Identify the collaborative role of the nurse when working with the interdisciplinary team when caring for the patient with chest pain, dyspnea, hypertension, and stroke. 3. Demonstrate critical thinking/clinical reasoning when caring for the patient with chest pain, dyspnea, hypertension, and stroke. 4. Implement basic leadership concepts for the purpose of providing and improving care for the patient with chest pain, dyspnea, hypertension, and stroke. 5. Use information technology to document care for the patient with chest pain, dyspnea, hypertension, and stroke. 6. Identify ways in which professional standards of legal and ethical conduct apply to safe, quality, patient-centered care for the patient with chest pain, dyspnea, hypertension, and stroke. rv1ajor Topics 1. Cardiovascular conditions: chest pain, hypertension, stroke 2. Dyspnea 3. Nursing care of the patient with chest pain, dyspnea, hypertension, and stroke. Required Reading lgnatavicius & Workman, Chapter 38, and pages 775-785. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Care of Patients with Common Conditions of the Cardiovascular System.doc 1/3/14 19 Anemias 1. Compare and select the appropriate lab lgnatavicius, Workman values for the specific anemias. 2. Contrast and compare the typical signs and symptoms of the following disorders: Chapter 41 a. Maturation and production of blood cell problems: Chapter 42 • megaloblastic (pernicious anemia) • iron deficiency anemia • aplastic anemia b. Clotting deficiency: • DIC c. Excessive destruction of RBC's: • Acquired hemolytic anemia 3. Analyze diagnostic tests, medical treatment, and nursing care for the above mentioned conditions and the related nursing interventions. 4. Examine counseling issues related to genetics, family planning, loss/grief, over protection and health issues such as AIDS risk, insurance etc. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Anemias.wpd January 6, 2014 20 1. Analyze the key respiratory physiologic principles lgnatavicius, applicable to this unit. Workman Chapter 29 2. Analyze the major signs and symptoms of a client with respiratory distress and utilize these in assessment. Chapter 30 3. Differentiate the various diagnostic tests used for a client with dyspnea. Also be to teach the client about test preparation and interpretation of abnormal findings. Relevant material 4. Assess and select specific care measures for a client for bronchoscopy and thoracentesis procedures. 5. For pulmonary tuberculosis and coccidiomycosis compare and contrast the following: a. transmission and risk factors b. pathophysiology and clinical manifestations c. diagnostic evaluation and medical management d. nursing implications including nursing diagnoses and plan of care for a client with dyspnea. 6. Analyze the principles of basic ABG's. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Dyspnea Objectives.wpd January 6, 2014 21 Care of Patients with Common Alterations in Gastrointestinal Function Purpose: The unit covers common alterations in gastrointestinal function. Gastrointestinal conditions are common and often times treated with over-the-counter medications. During the health history the nurse is alert to gastrointestinal conditions when taking the nutrition, elimination, and medication history. This data provide clues to issues the patient may have with acute or chronic Gl conditions. Experiences in the nursing laboratory include nasogastric tube insertion, maintaining, n1 onitoring, and discontinuing. Learning Objectives and Course Outcomes Specific student learning objectives appear at the beginning of each chapter. These will be used as the focus of the content. The specific content is then related to the following course outcomes: 1. Apply nursing concepts to plan patient-centered, evidence-based care taking into consideration individual differences, developmental level, and culture for the patient with common alterations in the gastrointestinal system. 2. Identify the collaborative role of the nurse when working with the interdisciplinary team when caring for the patient with common alterations in the gastrointestinal system. 3. Demonstrate critical thinking/clinical reasoning when caring for the patient with common alterations in the gastrointestinal system. 4. Implement basic leadership concepts for the purpose of providing and improving care for the patient with common alterations in the gastrointestinal system. 5. Use information technology to document care for the patient with a common alterations in the gastrointestinal system. 6. Identify ways in which professional standards of legal and ethical conduct apply to safe, quality, patient-centered care for the patient with common alterations in the gastrointestinal system. Major Topics 1. Common alterations in the gastrointestinal system. 2. Nursing care of the patient with common alterations in the gastrointestinal system. Nursing Skills Laboratory Assessment of the gastrointestinal system Nasogastric tubes - types Nasogastric tube insertion, maintaining, monitoring, and discontinuing Docun 1entation related to nasogastric tubes Required Reading lgnatavicius & Workman, Chapters 55, 57, 58 (Relevant material in Chapters 59-63) T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Care of Patients with Common Alterations in Gastrointestinal Function.doc 1/3/14 22 Care of Patients with Common Alterations in Urinary Function Purpose: The unit covers cmn1non alterations in urinary function. One of the most frequently occurring conditions is urinary tract infection, a problem that occurs more frequently in women than men. Other problems, such as urinary calculi, commonly occur in both men and wmnen. Experiences in the nursing laboratory include insertion, care of, and removal of urinary catheters and care of urinary diversions. Learning Objectives and Course Outcomes Specific student learning objectives appear at the beginning of each chapter. These will be used as the focus of the content. The specific content is then related to the following course outcomes: 1. Apply nursing concepts to plan patient-centered, evidence-based care taking into consideration individual differences, developmental level, and culture for the patient with com1non alterations in urinary function. 2. Identify the collaborative role of the nurse when working with the interdisciplinary team when caring for the patient with cotntnon alterations in urinary function. 3. Demonstrate critical thinking/clinical reasoning when caring for the patient with comtnon alterations in urinary function. 4. Impletnent basic leadership concepts for the purpose of providing and iinproving care for the patient with common alterations in urinary function. 5. Use information technology to document care for the patient with a common alterations in urinary function. 6. Identify ways in which professional standards of legal and ethical conduct apply to safe, quality, patient-centered care for the patient with cmntnon alterations in urinary function. Major Topics 1. Common alterations in urinary function. 2. Nursing care of the patient with cmnmon alterations in urinary function. Nursing Skills Laboratory Assessment of the urinary systen1 Insertion and removal of indwelling urinary catheter Insertion of straight catheter Urinary diversion Required Reading Ignatavicius & Workman, Chapters 68, 69, and 70 T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Faii2013\REGN 24\Care of Patients with Common Alterations in Urinary Function.doc 1/3/14 23 Care of the Patient with Diabetes Mellitus Purpose: This unit addresses an increasingly common condition in both adults and children. This condition is so pervasive that all patients should be routinely assessed for this condition. Covered in this unit are the common manifestations, complications, treatment options, patient teaching, and nursing care. Learning Objectives and Course Outcomes Specific student learning objectives appear at the beginning of each chapter. These will be used as the focus of the content. The specific content is then related to the following course outcomes: 1. Apply nursing concepts to plan patient-centered, evidence-based care taking into consideration individual differences, developmental level, and culture for the patient with diabetes mellitus. 2. Identify the collaborative role of the nurse when working with the interdisciplinary team when caring for the patient with diabetes mellitus. 3. Demonstrate critical thinking/clinical reasoning when caring for the surgical patient. 4. Implement basic leadership concepts for the purpose of providing and improving care for the patient with diabetes mellitus. 5. Use information technology to document care for the patient with diabetes mellitus. 6. Identify ways in which professional standards of legal and ethical conduct apply to safe, quality, patient-centered care for the patient with diabetes mellitus. Major Topics 1. The pathology of diabetes mellitus 2. Health pro1 notion and illness prevention 3. Nursing care of the patient with diabetes mellitus Required Reading 241-242. lgnatavicius & Workman, Chapter 67 T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Care of the Patient with Diabetes Mellitus. doc January 3, 2014 24 Care of Elderly Patients Purpose: The fastest growing segment of the population are those 65 years and older. The unit covers common changes with aging and how the nurse can adapt to these changes. The nurse must be able to differentiate between normal changes with aging and manifestations which may indicate pathologies. Early detection and treatment can assist the elderly to adapt and enjoy a quality life. The unit concludes with end of life care. Learning Objectives and Course Outcomes Specific student learning objectives appear at the beginning of each chapter. These will be used as the focus of the content. The specific content is then related to the following course outcomes: 1. Apply nursing concepts to plan patient-centered, evidence-based care taking into consideration individual differences, developmental level, and culture for the elderly patient. 2. Identify the collaborative role of the nurse when working with the interdisciplinary team when caring for the elderly patient. 3. Demonstrate critical thinking/clinical reasoning when caring for the elderly patient. 4. Implement basic leadership concepts for the purpose of providing and improving care for the elderly patient. 5. Use information technology to document care for the elderly patient. 6. Identify ways in which professional standards of legal and ethical conduct apply to safe, quality, patient-centered care for the elderly patient. Major Topics 1. Normal changes with aging 2. Manifestations that might indicate pathology ...J.~ D-""h,..,.hili-1-,.,..f.i,.,.,...I "\.CIIClUIIIlC:HIUII vUilvCjJl\::1""""""'"""'""' 4. End of life issues and care Nursing Skills Laboratory Focused assessment of the elderly Required Reading lgnatavicius & Workman, Chapters 3, 8, and 9 T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Care of Elderly Patients.doc January 3, 2014 25 1. Analyze the major risk factors for developing lgnatavicius cerebrovascular disorders. Chapter 47 pgs. 1004-1020 2. Differentiate the pathophysiology and clinical manifestations of transient ischemic attack, complete stroke, and subarachnoid hemorrhage (SAH). 3. Differentiate the signs and symptoms of persons with right and left hemipheric stroke. 4. Inventory the major medications and surgical procedures that may be used to treat cerebrovascular disorders. 5. Relate principles of nursing management to the care of a patient in the acute stage of stroke. 6. Plan for principles of nursing management to the care of the stroke patient in the rehabilitative stage. 7. Differentiate the traditional and neurodevelopmental (Bobath) approaches in the care and retraining of stroke patients. 8. Distinguish essential elements for family teaching and preparation for home care of the stroke patient. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 25\Cerebr2'escular Disorder Objectives.wpd July 18, 2013 Introduction to Care of Patients with Alterations in Musculoskeletal or Articular Function Purpose: The unit covers conditions interfering with muscularskeletal or articular functioning. Many of these conditions are treated with surgical intervention and/or traction. Both adults and children are addressed. Experiences in the nursing skills laboratory focus on traction, using crutches, canes, and walkers. Learning Objectives and Course Outcomes Specific student learning objectives appear at the beginning of each chapter. These will be used as the focus of the content. The specific content is then related to the following course outcomes: 1. Apply nursing concepts to plan patient-centered, evidence-based care taking into consideration individual differences, developmental level, and culture for the patient with an alteration in musculoskeletal or articular function. 2. Identify the collaborative role of the nurse when working with the interdisciplinary team when caring for the patient with an alteration in musculoskeletal or articular function. 3. Demonstrate critical thinking/clinical reasoning when caring for the patient with an alteration in musculoskeletal or articular function .. 4. Implement basic leadership concepts for the purpose of providing and improving care for the patient with an alteration in musculoskeletal or articular function. 5. Use information technology to document care for the patient with an alteration in musculoskeletal or articular function. 6. Identify ways in which professional standards of legal and ethical conduct apply to safe, quality, patient-centered care for the patient with an alteration in musculoskeletal or articular function. Major Topics 1 . Common alterations of musculoskeletal or articular function 2. Nursing care of the patient with an alteration in musculoskeletal or articular function Nursing Skills Laboratory Assessment of the musculoskeletal system Traction Using crutches, canes, and walkers Required Reading lgnatavicius & Workman, Chapters 52 and 53 T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Faii2013\REGN 24\lnto to Care of Patients with Alterations in Musculoskeletal or Articular Function.doc January 3, 2014 27 1. Differentiate the various characteristics of pain and relate lgnatavicius, how to use them while gathering data in assessment of a Workman patient with chest pain. 2. Distinguish among the major types of chest pain. Chap.40 Relevant material 3. Analyze risk factors, pathophysiology , chest pain descriptors and diagnostic screening for both Ml and Chap.35 angina. Relevant material 4. Prepare the client with chest pain both physically and with teaching for diagnostic tests. Also be able to interpret the tests. ACLS Provider 5. Compare and contrast the pathophysiology, stages in Manual development, medical management and development of complications for both a Ml and angina. Recommended resource 6. Assess and intervene with nursing management activities to relieve client symptoms of chest pain, in addition to assisting with the relief of anxiety related to the pain and fear of possible death. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 25\Coron~§ain Objectives.wpd July 18, 2013 s cti n The ry j cti,,,...... Dan Smith T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Dividers.wpd January 6, 2014 29 ~.·· ~9wtl~tfuiii<'·.J;·( WhitS February 3 1&2 Introduction to Maternity Nursing Lowdermilk: Chapters 1 & 2 5 1&2 Reproduction Concerns & Health Assessments Lowdermilk: Chapters 3 & 4 ATI: Chapters 1 & 2 10 1&2 Genetics ~~ Fetal Development Lowdermilk: Chapters 3 & 4 A Tl: Chapter 6 12 1&2 Anatomy 8" Physiology of Pregnancy Lowdermilk: Chapter 6 A Tl: Chapter 3 17 HOLIDAY 19 1&2 Nursing Care During Pregnancy I Maternal & Lowdermilk: Chapters 7 & 8 F1etal Nutrition ATI: Chapters 4 & 5 w 0 24 EXAM #2 26 3&6 Labor & Birth Processes Lowdermilk: Chapters 9 A Tl: Chapter 11 March 3 3&6 Nursing Care During Labor, including Lowdermilk: Chapters 10, 11, 12 Mlanaging Discomfort and Fetal Assessment ATI: Chapters 12, 13 5 3&6 Assessment of High Risk Pregnancy Lowdermilk: Chapter 19 ATI: Chapters 7, 8, 9, 10 10 3&6 Labor & Birth At Risk Lowdermilk: Chapters 22 ATI: Chapter 16 12 3&6 Postpartum Complications Lowdermilk: Chapter 23 ATI: Chapters 20, 21 17 EXAM#3 T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Faii2013\REGN 24\Dan's Class Schedule.wpd July 17, 2013 lf:aw.·.··•·······:d··· e.:> ·······il. I<' ;.Uriits··:•rm...... March 19 4&5 Maternal Physiological Changes Lowdermilk: Chapter 13 ATI: Chapter 17 24 4&5 Postpartum Nursing & Family Transition Lowdermilk: Chapter 14 & 15 ATI: Chapter 18, 19 26 4&5 Adaptations of the Newborn Lowdermilk: Chapter 16 A Tl: Chapter 23 31 4&5 Assessment of the Newborn Lowdermilk: Chapter 17 A Tl: Chapter 23 April 2 6 The Newbc:>rn At Risk Lowdermilk: Chapter 24 A Tl: Chapter 27 ~I 17 I IEXAM#4 9 ATIEXAM T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Faii2013\REGN 24\Dan's Class Schedule.wpd July 17, 2013 Care of the Childbearing Family: Pregnancy Purpose: This section is the first of a series on the childbearing family. It presents the pregnant patient. Pregnancy is a normal condition. Occasionally the pregnant patient may experience complications. Prenatal care is directed at keeping the patient and baby healthy and the prevention of problems. If problems do occur, early detection and treatment provide the best changes for positive outcome. The nursing skills laboratory learning experience focuses on assessment of the pregnant patient. learning Objectives and Course Outcomes Specific student learning objects appear at the beginning of each chapter. These will be used as the focus of the content. The specific content is then related to the following course outcomes: 1. Apply childbearing family nursing concepts to plan patient-centered, evidence based care taking into consideration individual differences, developmental level, and culture. 2. Identify the collaborative role of the nurse when working with the interdisciplinary team when care for the childbearing family. 3. Demonstrate critical thinking/clinical reasoning when caring for the childbearing family. 4. Implement basic leadership concepts for the purpose of providing and improving care for the childbearing family. 5. Use information technology to document care for the childbearing family. 6. Identify ways in which professional standards of legal and ethical conduct apply to safe, quality, patient-centered care for the childbearing family. Major Topics 1. The pregnant patient & reproductive concerns 2. Culturally competent care 3. The nurse as a patient advocate for the childbearing family .A 1\l,, .. ""j'"',.., ,...,.,. .. '"' ".f +h" .f,.,.I"V'\il" rl •• .-inn r·u·o.nn~n'"''' "1'. I'IUI;:)JII~ vQIC VI LIIC IQIIIIIJ UUIIII~ tJIC~ ICUivy 5. Anatomy and physiology of pregnancy 6. Fetal development Nursing Skills laboratory 1. Taking a health history of the pregnant patient 2. Physical assessment of the pregnant patient Required Reading Dillon: Chapter 14 Lowdermilk, Perry: Chapters 1, 7, and 8 Lowdermilk, Perry, Study Guide: Chapters 1, 7 and 8 T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Care of the Childbearing Family Pregnancy.wpd 32 Weekly Objectives Introduction to Maternity And Reproductive Health 1. Define the key terms listed. Lowdermilk 1,2,3,4 2. Distinguish contemporary issues in maternity nursing. 3. Compare social concerns in maternity care. Review Study Guides for 4. Construct a schedule for women's health promotion and Lowdermilk screening. ATI 5. Distinguish how assessment varies with culture, age, Chapters 1, 2 physical handicaps. 6. Construct steps for patient teaching of breast self-exam for early detection of cancer. 7. Differentiate between the internal, external and accessory structures of both the male and female reproductive systems. 8. Compare the function of both male and female reproductive systems. 9. Analyze the menstrual cycle in relation to hormonal, ovarian, and endometrial response. 10. Examine the four phases of the sexual response cycle. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall2013\REGN 24\Introduction to Maternity and Reproductive Health.docx 12/16/13 33 1. Define the key terms listed. Lowdermilk 2. Analyze health assessment of the pregnant Chapters 5 and 6 woman and fetus. ATI: 3. Propose a schedule for care during a normal pregnancy. Chapters 3, 6 4. Examine ethical dimensions of genetic screening. 5. Examine physiological and maternal adaptations to pregnancy that occur on a system level. 6. Evaluate the various diagnostic techniques and implications of findings. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Genetics & Fetal Dev- Anatomy & Physiology of Pregnancy.wpd 12/16/13 34 1. Discuss the physical, psychosocial, and behavior Lowdermilk changes as the mother and family adapt to the pregnancy. Chapters 7 and 8 2. Identify nursing assessments, interventions and ATI: methods of evaluation in providing care during pregnancy. Chapters 4 and 5 3. Discuss the benefits of prenatal care. 4. Identify barriers to prenatal care. 5. Examine the role of nutritional supplements during pregnancy. 6. Examine the nurse's role in prenatal and perinatal education. 7. Compare cultural food patterns and possible dietary problems for various ethnic groups. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Faii2013\REGN 24\Nursing Care During Pregnancy- Maternal & Fetal Nutrition.wpd 12/16/13 35 Care of the Childbearing Family: Labor & Delivery and Postpartum Purpose: This section addresses the nursing care of the patient in labor and delivery, then in the postpartum period. This is a crucial period for both the mother and infant, both physiologically and emotionally. Bonding among the mother, father, and baby occurs at this time and it is part of the nurse's assessment. The postpartum period is also a time of heavy emphasis on family teaching. The nursing skills laboratory learning experiences focuses on assessment of the postpartum patient and potential complications. Learning Objectives and Course Outcomes Specific student learning objects appear at the beginning of each chapter. These will be used as the focus of the content. The specific content is then related to the following course outcomes: 1. Apply childbearing family nursing concepts to plan patient-centered, evidence based care taking into consideration individual differences, developmental level, and culture. 2. Identify the collaborative role of the nurse when working with the interdisciplinary team when care for the childbearing family. 3. Demonstrate critical thinking/clinical reasoning when caring for the childbearing family. 4. Implement basic leadership concepts for the purpose of providing and improving care for the childbearing family. 5. Use information technology to document care for the childbearing family. 6. Identify ways in which professional standards of legal and ethical conduct apply to safe, quality, patient-centered care for the childbearing family. Major Topics 1. The laboring patient 2. The baby during the labor and birth process 3. Labor and Birth Risks 4. Care of the family during the immediate postpartum period Nursing Skills Laboratory 1. Assessment of the patient during labor and birth 2. Assessment during the postpartum period Required Reading Lowdermilk, Perry: Chapters 9, 10, 11, 12, 19, 22, 23 Lowdermilk, Perry, Study Guide: Chapters 9, 10, 11, 12, 19, 22, 23 T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Care of the Childbearing Family Labor and Delivery and Postpartum.wpd 36 1. Define key terms. Lowdermilk 2. Analyze factors affecting labor, including Chapters 9, 10, 11, 12 anatomical structure. 3. Assess the maternal and fetal adaptations to labor. 4. Distinguish factors involved in the assessment of a woman in labor. ATI: 5. Analyze the processes of labor. Chapters 11, 12, 13 6. Compare techniques, strategies and methods for managing pain during childbirth. 7. Propose nursing diagnoses and develop a plan of care for a woman throughout the four stages of labor. 8. Assess and evaluate maternal and fetal changes during labor. 9. Compare beliefs/practices of selected cultures about labor and birth. 10. Compare the role of the nurse and support persons during the four stages of labor. 11. Evaluate interventions for possible complications and pain relief. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Nursing Care During Labor & Delivery- Managing Discomfort & Fetal Assessment.docx 12/16/13 37 1. Examine risk factors identified through patient Lowdermilk history, examination of diagnostic procedures. Chapter 19, 20, 21 2. Describe the pathophysiology of preeclampsia and eclampsia. ATI: 3. Describe HELLP Syndrome and appropriate Chapters 7, 8, 9, 10, 16 nursing actions. 4. Compare and contrast Placenta Previa and Abruptio Placentae related to nursing interventions, recognitions of signs and symptoms as well as potential complications to maternal and fetal well being. 5. Analyze and differentiate between the signs and symptoms, as well as the treatment plan for miscarriages, ectopic pregnancies and hydatidiform mole. 6. Propose nursing interventions for the treatment of hyperemesis gravidarum. 7. Differentiate the types of Diabetes Mellitus and their respective risk factors in pregnancy. 8. Examine maternal and fetal risk or complications associated with diabetes in pregnancy. 9. Analyze care management for the pregnant woman with pregestational or gestational diabetes. T:\RN-LVN-Nursing\MyFiles\Nursing~RN\Syllabi\Fall 2013\REGN 24\Assessing High Risk Pregnancy Labor and Birth.wpd December 17, 2013 38 1. Identify and differentiate the anatomic and physiologic Lowdermilk changes that occur during the postpartum period. Chapter 23 2. Compare components of a systematic postpartum assessment and list expected values for vital signs. 3. Identify signs of complications in the postpartum woman. ATI: 4. Analyze the nurse's role in postpartum teaching and follow Chapters 20, 21, 22 up care. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Post Partum Care Objectives.wpd December 16, 2013 39 Care of the Newborn Purpose: This section continues to address postpartum care as well as the nursing care of the newborn. Within the first 24 hours the newborn goes through remarkable changes in the transition to the extrauterine life. The nurse is always on alert to distinguish normal from abnormal changes. Assessment is crucial during this time with both the mother and newborn. Learning Objectives and Course Outcomes Specific student learning objects appear at the beginning of each chapter. These will be used as the focus of the content. The specific content is then related to the following course outcomes: 1. Apply childbearing family nursing concepts to plan patient-centered, evidence based care taking into consideration individual differences, developmental level, and culture. 2. Identify the collaborative role of the nurse when working with the interdisciplinary team when care for the childbearing family. 3. Demonstrate critical thinking/clinical reasoning when caring for the childbearing family. 4. Implement basic leadership concepts for the purpose of providing and improving care for the childbearing family. 5. Use information technology to document care for the childbearing family. 6. Identify ways in which professional standards of legal and ethical conduct apply to safe, quality, patient-centered care for the childbearing family. Major Topics 1. Care of the newborn 2. Care of the family during the postpartum period 3. Postpartum complications 4. The newborn at risk Nursing Skills Laborator'J 1. Newborn care 2. Bathing the newborn 3. Newborn assessment Required Reading Dillon, Chapter 15 Lowdermilk, Perry: Chapters 13-17, and 24 Lowdermilk, Perry, Study Guide: Chapters 13-17, and 24 T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Care of the Newborn.wpd 40 1. Describe the anatomic and physiologic changes that occur Lowdermilk during the postpartum period. Chapters 13, 14, 15 2. Explain the influence of cultural beliefs on postpartum care and transition of the newborn into the family. 3. Discuss nursing management and interventions for women ATI: during the postpartum period. Chapters 17, 18, 19 4. Recognize signs of complications in the postpartum woman. 5 Describe how the nurse can facilitate parent-infant adjustments and bonding. 6. Examine the effects of the following on parental response: parental age, social support, culture, socioeconomic conditions. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Faii2013\REGN 24\Postpartum Maternal Physiological Changes and Family Transition.wpd January 3, 2014 41 1. Define the key terms listed. Lowdermilk 2. Distinguish physical and behavioral characteristics of the newborn. Chapters 16, 17, 18 3. Select the essential features for a newborn assessment. 4. Assess reflexes of a newborn. ATI: 5. Examine the method and purpose of APGAR scoring. Chapters 23 6. Propose safety steps for maintenance of temperature, airway, and oxygen supply. 7. Select key points for parent teaching if the newborn must have phototherapy. 8. Examine the purpose and methods of circumcision, post procedure care, and parent teaching. 9. Analyze procedures for heel stick, collection of urine specimen, and restraining the newborn. 10. Plan home care of a newborn. 11. Select fluid and nutrient needs of the newborn. 12. Compare nutritional value of breast milk with infant formula. 13. Evaluate differences in infant response, breast care, diet and fluids as the parents are taught about infant feeding choices. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Newborn Care and Nursing Care of the Newborn .wpd December 16, 2013 42 Absent Slow, Weak, Cry Good Cry Flaccid Slight Flex Well Flexed No Response Grimace Cry Blue, Pale Body Pink All Pink Extremities Blue T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\APGAR.wpd December 16, 2013 43 1. Define the key terms. Lowdermilk Chapter 24 2. Assess and evacuate complications associated with pre and post term infants 3. Examine the effects substance abuse during pregnancy ATI: has on the new born. Chapter 27 4. Distinguish and compare various neonatal infections. 5. Analyze care management for infants with congenital abnormalities. 6. Develop a teaching plan to explain collaboration care of at risk infants. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Complications of the Newborn.wpd December 16, 2013 44 cti n linical Inform tion T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Dividers.wpd January 6, 2014 45 Scavenger Hunt Mercy Medical Center Merced Student Name: ______Unit of Orientation: _____Date: ______ Directions: I. The following information may be collected alone or with one or two other students. II. Questions 1-15 are to be completed in writing and placed in your folder on the first Thursday of clinical - use handout to write responses. Ill. Be brief in written responses. A. Be able to locate areas as outlined on map B. For the Unit you are assigned: 1. Where are the Nursing Policy/ Procedure Manuals kept? 2. How do you call a CODE BLUE? 3. How do you report a fire? 4. Locate the Fire escape routes from the area and describe where they are. 5. What are the room numbers for the Unit? 6. Where are the Med Carts kept? 7. Identify the Omnicell System? Give some examples of its use. 8. Locate the supply areas on each floor. 9. Find the location of the reflux protective masks you would need for CPR. 10. V\fhere is the Crash Cart kept? 11 . How are Lab reports received? 12. Where is the Census Board located? 13. Where is the Family Waiting Room? How often do families visit and what is the procedure for contacting staff? 14. When/how is the quality control check done on the One Touch? 15. What is the procedure for replacing a patient identification band? What colors are used with identification bands and why? T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Scavenger Hunt.wpd January 6, 2014 46 Make a checkmark and date it (after the section), as you complete Questions 16 -18 16. Find an empty patient room: Check how the wall suction works, How the 0 2 is turned on and off, Location of Code button in room and bathroom. 17. Also in a patient room: Sharps boxes Waste paper baskets, Sinks Where charge sticker cards are located, Bedside bags Gloves, How beds and side rails work, Call lights and TV are located and function, Method for maintaining patient privacy for an exam, Where contaminated dressings etc. are disposed. 18. Be able to describe the use of the following forms: Admission Assessment Form Intake and Output Patient Care Plan Drs Order Form MAR MD Progress Record Nursing Discharge Summary Patient Progress Record Transfusion Record Graphics Record Surgical Check List Surgical Permit Clothing List Acuity Documentation Approved Standard Abbreviation List T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Scavenger Hunt.wpd January 6, 2014 47 cti n E utmigrati n lnf rmati n T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Dividers.wpd January 6, 2014 48 Outmigration Clinical Instructions (General) REGN 24 CLINICAL practice moves away from acute care for some of your clinical rotations. We expect these weeks will be beneficial experiences that add to your knowledge base. These instructions should help smooth the transition. 1. Your clinical obligation is 15 hours for each of these rotations. Some time will also be at the designated acute care facility. If for some reason the usual hours of the outpatient facility is not being observed (e.g. low census, unexpected meeting etc.) call the instructor to talk over the situation before you leave the facility. 2. Review and bring to the designated outpatient facility the clinical objectives, guidelines etc. for each specific rotation. If you do not have the appropriate paper work, it must be completed before you start your assignment and you will be counted as tardy or partial absence form clinical. 3. Lunch breaks are according to the facility policy - usually an hour. 4. Professional appearance is expected. Wear your uniform except for the OR assignment. For ALL sites, Name tags must be clearly visible at all times. 5. You are professionally accountable and expected to be present and on time for each assignment. It is UNACCEPTABLE to be absent or tardy without contacting the instructor ASAP. Do not rely on other students to relay a message. 6. The Outmigration Instructor is available by beeper at all times on Tuesdays while you are in the assigned clinical area. An instructor will be available to assist you with immunizations in the pediatric clinics. 7. When the instructor makes clinical rounds, you are expected to make yourself and your designated paperwork available. 8. Medication administration, invasive or sterile procedures, are NOT to be done without instructor. T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\0utmigration lnstructions.wpd January 3, 2014 49 Pediatric Clinic Guidelines Note: You must have these Guidelines, Completed Pediatric Clinic Med Sheet, and Clinic Peds packet (from class) physically with you in the Clinic at the time of rotation. Also bring you Pediatric and Drug textbooks with you. The student will actively participate in the following: 1. Clinical assignments a. With assistance of staff prepare pediatric patients for admission procedures to the facility within the guidelines and time frame of the facility. b. Measure height/length, weight, and head circumference if indicated. c. Complete vital sign assessment. d. Assist physician/nurse practitioner with pediatric exams. e. Participate in teaching child and caretaker as appropriate. f. Observe/assist with hemoglobin finger stick testing. g. Perform immunizations with assistance of instructor or clinic designee. h. Assist with discharge procedures including any follow-up teaching. i. Complete charting as appropriate with supervision of clinic staff. 2. Written Pediatric Folder Requirements Weekly: a. Medication Sheet- Immunization medications and others specified. b. From the clients available select one from the pediatric groupings - infant, toddler, pre school, or school age. Using Wong's Essentials of Pediatric Nursing compare the child you selected with expected normal growth and development patterns. Document your findings on the Growth and Development Patterns Sheet. c. Self Evaluation d. Tracking Sheet e. Summary of your experience - limit one page T:\RN-LVN-Nursing\MyFiles\Nursing\RN\Syllabi\Fall 2013\REGN 24\Pediatric Guidelines.wpd January 6, 2014 50